Academic literature on the topic 'Dual diagnosis Patients Australia'

Purpose The purpose of this paper is to inform the development of an evidence-based and effective rehabilitation programme to address substance use disorders in a population of patients with severe mental illness and mental disorders detained in a secure forensic psychiatric facility. A clinical review identified a high prevalence of substance use disorders in the patient population at a secure forensic facility in Sydney, Australia with only a limited number of patients being assessed and offered interventions for substance use problems. Design/methodology/approach A literature review was undertaken specifically looking at articles between 2009 and 2017 that considered models of care or approaches to substance use rehabilitation in patients with co-morbid psychiatric disorders. Articles were considered based on their relevance to the purpose and the environment of a secure forensic facility. Findings The literature review emphasised the need for a cohesive model of care integrating substance use rehabilitation with mental health care. Comprehensive assessment and individualised approaches that incorporated patient choice and stages of change were considered essential components to any dual diagnosis rehabilitation programme. Practical implications The literature regarding rehabilitation approaches for those with severe mental illness and co-morbid substance use disorders was reasonably consistent with the models of care used in relation to criminal offenders and mental illness generally. Integrated and individualised rehabilitation approaches for dual diagnosis patients could play a significant role in forensic settings. Originality/value Limited robust evidence for substance use rehabilitation has been published. The authors consider the existing evidence base and the underlying theory behind substance use rehabilitation to propose a model for rehabilitation in secure forensic settings. This is the first known review of substance use rehabilitation involving mentally ill offenders with dual diagnoses in secure forensic settings. This paper is the original work of the authors.

Background: Although the poor health of people experiencing homelessness is increasingly recognised in health discourse, there is a dearth of research that has quantified the nature and magnitude of chronic health issues and morbidity among people experiencing homelessness, particularly in the Australian context. Methods: Analysis of the medical records of 2068 “active” patients registered with a specialist homeless health service in Perth, Western Australia as of 31 December 2019. Results: Overall, 67.8% of patients had at least one chronic physical health condition, 67.5% had at least one mental health condition, and 61.6% had at least one alcohol or other drug (AOD) use disorder. Nearly half (47.8%) had a dual diagnosis of mental health and AOD use issues, and over a third (38.1%) were tri-morbid (mental health, AOD and physical health condition). Three-quarters (74.9%) were multimorbid or had at least two long-term conditions (LTCs), and on average, each patient had 3.3 LTCs. Conclusions: The study findings have substantial implications from both a health risk and healthcare treatment perspective for people experiencing homeless. The pervasiveness of preventable health conditions among people experiencing homelessness also highlights the imperative to improve the accessibility of public health programs and screening to reduce their morbidity and premature mortality.

Introduction:While medicines and medical tests are developed in a controlled clinical trial environment, postmarketing surveillance in the real world can be challenging. MedicineInsight—a database of longitudinal patient-level clinical information from primary care practices in Australia—is a novel program that collects primary care data to improve postmarketing surveillance at a national level.Methods:MedicineInsight collects de-identified clinical information from primary care practice information systems using data extraction tools. MedicineInsight currently includes 3.6 million regular patients of 3,300 family physicians (general practitioners) from 650 primary care practices across Australia. MedicineInsight data include longitudinal clinical information on diagnosis and medicines (dose, strength, route of administration, medication switches over time, adverse events, and allergies), and pathology testing data. A series of observational studies was developed for postmarketing surveillance of management of a range of health priorities including type 2 diabetes mellitus (T2DM), chronic obstructive pulmonary disease (COPD), depression, and antibiotics use.Results:Forty-four percent of patients with T2DM in the MedicineInsight database did not have a recorded hemoglobin A1c result and thirty-one percent did not have a recorded blood pressure reading in the previous 6 months. While guidelines recommend a stepwise approach to the initiation of COPD therapy, forty-nine percent of patients with COPD (with or without asthma) were prescribed dual therapy at initiation and a small number (4.5 percent) were prescribed triple therapy. Between 2011 and 2015, the annual rate of antidepressant prescribing per 1,000 family physician encounters increased by eight percent. High volumes of antibiotics were prescribed for respiratory tract infections in Australian primary care, notwithstanding guideline recommendations that antibiotics are not recommended in most cases.Conclusions:Large scale, real-world clinical data from primary care practices can play an important role in postmarketing surveillance at a national level.

e21053 Background: KRAS is frequently mutated in NSCLC, especially in Caucasian populations. Until recently there have not been effective targeted therapies against KRAS but the recent advent of active agents has thrown a spotlight on this disease. Methods: A database of NSCLC cases undergoing lobectomy or pneumonectomy with curative intent at Austin Health, Victoria, Australia was examined. Analysis for KRAS mutations was carried out using the LungCarta panel. Results: Four hundred and fifty nine cases underwent mutation analysis and 203/459 (44%) were wild type. KRAS mutations were identified in 100/459 cases (21.8%), including 3 cases where the specific mutation was not specified. KRAS G12C cases comprised 40/97 (8.5% of all cases, 41% of specified mutation KRAS cases) and other KRAS mutations comprised 57/97 (59%) - most commonly G12V (25 cases) and G12D (13 cases). Additional mutations were identified in 14/40 (36%) G12C mutation cases (10 dual and 4 triple – most commonly TP53 9, STK11 3 and PIC3CA 2). In non-G12C cases, multiple mutations were identified in 24% of cases. Considering the 40 G12C cases, histology was squamous cell in 21 cases, adenocarcinoma 13 and other 5. Males comprised 21/40 cases, median age at diagnosis was 61 year (range 34 – 78), with stage I 22 cases, stage II 12; stage IIIA 5 and one stage 4 (solitary brain metastasis). Thirty six patients (90%) had smoked tobacco with median exposure of 44 pack years (range 13-100) including 18 ex-smokers who had ceased a median 9 years (range 1 - 28) prior to the diagnosis of lung cancer. PD-L1 expression was analysed using the 28-8 antibody. For the 38 cases analysed, PD-L1 expression was ≥ 50% in 6 (16%), ≥ 5% in 12 (32%) and < 1% in 24 (63%). The estimated median overall survival was 4.9 years with 27% 10 year survival. Twenty three patients (58%) died from the index lung cancer, 8 (20%) remain alive and 9 (23%) died of other causes: 4 from a 2nd lung cancer, 4 from a non-lung cancer and one from liver failure. Data on sites of recurrence were available for 16 of the 23 cases who died from the index lung cancer, with initial recurrence sites being lung/local 7 patients, brain 6, bone 2, liver 1. A total of 9 patients (56%) developed brain metastases at some time. Conclusions: KRAS G12C is a common subgroup of NSCLC in the Australian population and almost all of cases were tobacco smokers. Additional mutations were identified in over a third of cases. Locally recurrent disease or brain metastases are the most frequent sites of relapse and over half of patients with recurrent disease develop brain metastases.

Background:A substantial proportion of primary care osteoarthritis (OA) consultations are associated with an X-ray request (1,2). Uncertainty exists regarding the ability of radiography to improve a clinical OA diagnosis, and the over-use of radiography may lead to inappropriate referrals due to severe radiographic features that do not correlate with patients’ symptoms. Additionally, there are cost implications of unnecessarily imaging such a prevalent disease. As evidence questions the utility of routine radiography in OA, the extent to which radiography is supported by international guidelines is unknown.Objectives:To undertake a systematic review and narrative synthesis of UK and international guideline recommendations on the role of radiography in the diagnosis of OA.Methods:A systematic search of eleven electronic databases (including EMBASE, MEDLINE CINAHL, Epistemonikos and Guideline Central) and the websites of nine professional organisations (including NICE, Royal College of Radiologists (RCR), EULAR, and the American College of Radiology (ACR)) identified the most recent evidence-based guidelines produced by professional organisations on the role of imaging in OA. Guidelines not addressing the role of radiography in the diagnosis of OA were excluded, as were non-English and spinal OA guidelines. Each title was screened by one reviewer whilst each abstract and full text underwent dual screening. A single reviewer, using a standard proforma, undertook data extraction. Each guideline was independently appraised by two reviewers using the AGREE II tool. A narrative synthesis of the nature and consistency of OA radiographic recommendations was performed.Results:18 evidence-based OA guidelines published between 1998-2019 were included. These guidelines considered OA at any joint (n=8), or at the knee (n=3), hip (n=2), hand (n=2), wrist (n=1), foot (n=1), and ankle (n=1). Seven guidelines were produced by European organisations; four guidelines were produced by EULAR. Guidelines were targeted at general practitioners (n=11), radiologists (n=7), rheumatologist (n=4) and orthopaedic surgeons (n=3). Using the AGREE II tool, the identified guidelines scored highly on rigour of development (mean score 69%) but poorly on applicability (32%). All 18 guidelines recommended X-rays as the first-line modality, where imaging was indicated. A clinical diagnosis of OA without radiographic confirmation was recommended by all eleven guidelines produced by organisations represented general practitioners, with seven guidelines justifying this due to a poor correlation between radiographic features and clinical symptoms. Only three guidelines explicitly discouraged the routine use of radiography for the diagnosis of OA and only two guidelines reassured practitioners of a low probability of missing serious pathology when not routinely requesting radiographs. Guidelines produced by organisations representing radiologists were more supportive of radiography. The ACR recommended radiographic confirmation in patients suspected to have OA at the hand, wrist, hip, knee, ankle, and foot. Conversely, the RCR recommended radiographic confirmation in patients suspected to have OA at the hand, feet, and hip, but not the knee.Conclusion:Differences in guideline recommendations on the utility of radiography in OA appear related to country/region, professional organisation, and joint. The use and utility of radiography in OA may need to be reviewed in light of a shift towards remote consultations, a change that has been accelerated by COVID-19 in many countries.References:[1]Yu D, Jordan K, Bedson J, Englund M, Blyth F, Turkiewicz A et al. Population trends in the incidence and initial management of osteoarthritis: age-period-cohort analysis of the Clinical Practice Research Datalink, 1992–2013. Rheumatology. 2017;56(11):1902-1917.[2]Brand C, Harrison C, Tropea J, Hinman R, Britt H, Bennell K. Management of Osteoarthritis in General Practice in Australia. Arthritis Care & Research. 2014;66(4):551-558Acknowledgements:JJE is funded by an Academic Clinical Lectureship from the National Institute for Health Research (NIHR) for this research project (CL-2016-10-003). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.Disclosure of Interests:None declared

Abstract BACKGROUND Adding pertuzumab to trastuzumab in patients (pts) with HER2+ breast cancer improves pathological complete response (pCR) rates. Pertuzumab + trastuzumab + chemotherapy is approved in Australia as neoadjuvant therapy in early stage (&gt;2 cm or node positive), locally advanced and inflammatory HER2+ breast cancer. This study captured real-world data on the safety and effectiveness of pertuzumab in the neoadjuvant setting. METHODS PeRSIA (ML39622) is a secondary data use non-interventional study of pts initiating neoadjuvant pertuzumab treatment for non-metastatic HER2+ breast cancer. The primary objective is to assess the effectiveness and safety of neoadjuvant pertuzumab when added to trastuzumab in the real-world setting. Deidentified data obtained from the pts’ medical notes were captured using REDCaP, hosted at the Walter and Eliza Hall Institute of Medical Research. This analysis reports the co-primary endpoints of breast pCR (bpCR) with or without in situ disease (ypT0/is or ypT0), total pCR (tpCR) with or without in situ disease (ypT0/is ypN0 or ypT0 ypN0), and the incidence of adverse events (AEs) related to pertuzumab. Secondary objectives include describing rates of breast and nodal surgery, relapse free survival (RFS) and overall survival (OS). RESULTS Ninety five pts receiving neoadjuvant pertuzumab were enrolled between March 2018 and July 2019, with data available for all pts. HER2-targeted neoadjuvant treatment was completed in 91 pts (95.8%) with a median number of 4 cycles [range 1-6] of pertuzumab and 5 cycles [range 1-6] of trastuzumab. Four pts did not complete the planned neoadjuvant therapy due to early CR (n=1), and pertuzumab-related AEs (n=3). The most common neoadjuvant chemotherapy regimens were sequential anthracyclines + taxanes (n=59, 62.1%) and single agent taxane (n=29, 30.5%). Surgery was performed in 92 pts (96.8%). Three pts did not proceed to surgery due to patient decision (n=1), physician decision (n=1), and development of a new non-breast cancer which resulted in death (n=1). Of those pts that underwent surgery, 65/92 (70.7%) had a bpCR and 59/92 (64.1%) had a tpCR. All pts who did not achieve a pCR obtained a partial response (33/92, 35.9%). Total pCR was seen in 27/34 (79.4%) pts with hormone receptor-negative and 32/58 (55.2%) pts with hormone receptor-positive cancers. 27/95 (28.4%) pts experienced an AE related to pertuzumab; diarrhea (21.1%) and rash (4.2%) were the most common AEs. Three pts (3.2%) discontinued pertuzumab due to an AE: cardiac toxicity, diarrhea and rash (n=1), cardiac toxicity (n=1), and diarrhea and sepsis (n=1). Following surgery, 93/95 (97.9%) patients received adjuvant HER2-directed therapy, and 4/95 (4.2%) received adjuvant chemotherapy. After a median follow-up from diagnosis of 21.2 [14.0-83.9] months, the RFS and OS were 92.6% and 99.0% respectively. Disease recurrence occurred in 6 pts (distant n=4, contralateral n=2). CONCLUSIONS This is the first multicenter, observational study of neoadjuvant therapy based on dual blockade with pertuzumab and trastuzumab for HER2+ non-metastatic breast cancer in Australia. The pCR rates achieved were numerically higher than previously reported in clinical trials. There were no significant safety findings outside of the expected safety profile for pertuzumab. Acknowledgments: Study sponsored by Roche Products, Pty. Limited. Theresa Wade (WriteSource Medical) provided medical writing. Table: Baseline Characteristics (n=95)CharacteristicNumber (%)Age, median (range)50.3 (24.4 -82.1)Charlson Comorbidity Index- 077 (81.1)- 19 (9.5)- 2 +9 (9.5)Tumour Size12 (12.6)- T156 (59.0)- T225 (26.3)- T3- Unreported2 (2.1)Tumour Grade- 10 (0)- 231 (32.6)- 362 (65.3)- Unreported2 (2.1)Nodal status- Positive63 (66.3)- Negative32 (33.7)Hormone Receptor Status- HR+60 (63.2)- HR-35 (36.8)Median baseline left ventricular ejection fraction (range)65.0% (35-79)Cardiac risk factors- 053 (55.8)- 122 (23.2)- 2+20 (21.1) Citation Format: Sheau Wen Lok, Richard De Boer, Sallt Baron-Hay, Peter Button, Bianca Devitt, Benjamin Forster, Peter Fox, Michael Harold, Sahisha Ketheeswaran, Ganessan Kichenadasse, Belinda E Kiely, Gavin Marx, Louise Nott, Laura Pellegrini, Ali Tafreshi, Peter GIbbs. Pertuzumab study for HER2-positive non-metastatic breast cancer in the neoadjuvant setting in Australia [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-13-38.

Dual Diagnosis (DD) is the co-occurrence of a Severe Mental Illness (SMI), commonly a major psychotic or affective disorder, and a Substance Use Dependence Disorder (SUD). It is a highly prevalent disorder with a large impact in clinical and health care systems due to the complications arising from the comorbidity between both conditions. The aim of this work is twofold: the study of the cognitive performance and the Health Related Quality of Life (HRQOL) in patients with DD. The first one, because few studies have examined this question and its assessment is of great interest, since cognitive functioning is related to the clinical course and may even be a predictor of failure or success of the therapeutic interventions. Although major cognitive impairments can be expected in DD due to the additive effects of both psychiatric disorder and SUD, a wide review of published results on the scientific literature suggest that their cognitive functioning depends, among others, on the main substance of choice, the assessed cognitive domain and the age of the participants. Thus, we focus on the assessment of the executive functioning on one hand, and on the domains of attention, memory and speed of processing on the other, in a sample comprised by subjects with schizophrenia and cocaine dependence (SZ+; n = 30) compared to subjects with schizophrenia without SUD history (SZ-; n=30) and to cocaine dependent subjects without psychiatry comorbidity (COC; n=35). Although in the last decades there has been an increased interest in the Quality of Life as an assessment measure as well as an indicator of the effectiveness of interventions in both SMI and SUD, few studies had focused on DD. For this reason, the second objective of this work was to assess HRQOL in a group with DD (n = 35) and compare it to a group with SMI (n=35) and to another one with SUD (N=35) without comorbidity. Regarding the cognitive functioning, the results showed a similar pattern of performance in the SZ+ and COC groups in neuropsychological tasks related to executive functions, being their performance better than the SZ- group. This may suggest that patients with SZ+ have higher cognitive skills than the SZ- ones. Therefore, the SZ+ patients may be a subgroup of SZ with lower biological vulnerability to develop the illness and maybe, a better psychosocial premorbid functioning, making them more able to acquire the illegal substance of abuse. In the domains of attention, memory and speed of processing, the COC group performed better than both SZ+ and SZ- groups, without differences between them. However, the age was negative related to the cognitive performance in the SZ+ group. So, the older SZ+ showed worse cognitive functioning. Otherwise, the SZ- patients showed a stable cognitive functioining regardless of the age. This, in agreement with the idea of an additional cognitive impairment to the psychiatric disorder manifested in older SZ+ patients because of the long term expression of the neurotoxic consequences of consumption. Concerning HRQOL, all the groups showed lower scores compared with the normative Spanish data. The DD group showed the worst scoring in most of assessed scales and in the mental domain, while the SUD group obtained the best, and the SMI obtained intermediate scores. The worse state in the mental domain appeared strongly related to the number of suicide attempts, daily intake of medication and to the caffeine consumption, only in the DD group. The systematic assessment of the HRQOL status could be a useful tool in the detection of specific care areas, helping to improve the treatment goals as well as an assessment measure of the effectiveness of interventions applied to DD patients. Overall, our results suggest particular characteristics in subjects with DD regarding cognitive performance and HRQOL status, which make them different to the subjects with SMI and SUD. This demonstrates the interest to study DD as a specific diagnostic entity. However, further research in this field, incorporating long term measures and biological parameters, could help to a better understanding of the current knowledge in DD and to increase the benefits in the clinical management of these patients.
Se denomina Patología Dual (PD) a la coocurrencia de un Trastorno Mental Severo (TMS), especialmente de la esfera psicótica y/o afectiva y un trastorno por uso de sustancias (TUS). Se trata de un trastorno de elevada prevalencia, con una gran repercusión clínica y asistencial debido a las complicaciones asociadas a la comorbilidad entre ambas patologías. El presente trabajo se propuso dos objetivos, estudiar el rendimiento cognitivo y la calidad de vida Relacionada con la Salud (CVRS) en pacientes con PD. El primero dada la escasez de estudios y la importancia de su evaluación, puesto que el funcionamiento cognitivo se relaciona con el curso clínico de la PD y puede incluso ser un factor predictivo del éxito o fracaso de las intervenciones terapéuticas. Si bien cabrían esperar importantes déficits cognitivos en los pacientes duales, debido a los efectos aditivos del trastorno psiquiátrico y del TUS, una revisión bibliográfica exhaustiva de los principales resultados publicados sugiere que su funcionamiento cognitivo depende, entre otros factores, de la sustancia principal de abuso, del dominio cognitivo evaluado y de la edad de los participantes. Así, nos centramos en evaluar el funcionamiento ejecutivo por una parte y los dominios de atención, memoria y velocidad del procesamiento de la información por otra, en una muestra de pacientes con esquizofrenia y dependencia a la cocaína (SZ+; n=30) comparados con esquizofrénicos sin historia de TUS comórbido (SZ-; n=30) y un grupo con dependencia a la cocaína sin comorbilidad psiquiátrica (COC; n=35). Aunque en las últimas décadas se ha producido un aumento en el interés de la Calidad de Vida como medida de evaluación y como un indicador de la eficacia de las intervenciones en los TMS y en los TUS, los estudios en la PD son pocos. El segundo objetivo de este trabajo fue evaluar la CVRS en pacientes con PD (n=35), con sólo TMS (n=35) y con sólo TUS (n=35). Los resultados del rendimiento cognitivo mostraron un patrón de actuación similar en los grupos SZ+ y COC en tareas neuropsicológicas dependientes del funcionamiento ejecutivo, siendo el rendimiento de ambos grupos mejor que el del grupo SZ-. Esto podría sugerir que los pacientes SZ+ poseen mayores habilidades cognitivas que los SZ-, y por tanto, pudiendo ser un subgrupo de SZ con menor vulnerabilidad biológica a desarrollar la enfermedad, presentando mayores habilidades ejecutivas y quizás, un mejor funcionamiento psicosocial premórbido que les haría más hábiles para adquirir las sustancias ilegales. En los dominios de atención, memoria y velocidad del procesamiento de la información, el grupo COC presentó un mejor rendimiento que los grupos SZ+ y SZ-, los cuáles no presentaron diferencias entre ellos. Sin embargo, la edad mostró una asociación negativa con la ejecución cognitiva en el grupo SZ+, los pacientes de mayor edad mostraban peor rendimiento cognitivo. En cambio, el grupo SZ- presentaba un déficit cognitivo estable independiente de la edad. Esto es coherente con la idea de un déficit cognitivo adicional al del trastorno psiquiátrico manifestado en los pacientes duales de mayor edad, debido a la expresión a largo plazo de las consecuencias neurotóxicas del consumo. En cuanto a la CVRS, todos los grupos aportaron peores puntuaciones de CVRS respecto a los valores normativos españoles. En la mayoría de subescalas y especialmente en el dominio de salud mental, el grupo con PD mostró las peores puntuaciones, el grupo TUS las mejores y el grupo TMS se situó en una posición intermedia. El peor estado en el dominio mental de la CVRS apareció estrechamente relacionado con los intentos de suicidio, el número de medicamentos diarios y el consumo de cafeína en el grupo PD. La evaluación sistemática del estado de la CVRS puede ser útil en la detección de áreas de atención específica para los objetivos del tratamiento, así como medida de la eficacia de las intervenciones aplicadas a la PD. Nuestros resultados sugieren características de rendimiento neuropsicológico y de CVRS particulares de los pacientes con PD, que los diferencian de aquellos con diagnóstico sólo de TMS o TUS. Ello evidencia el interés de estudiar la población dual como una entidad diagnóstica específica. Sin embargo, se requieren investigaciones futuras que progresen en esta línea de trabajo incorporando además, parámetros neurobiológicos y medidas longitudinales, lo que puede ayudar a mejorar el conocimiento actual de la PD y revertir en beneficios para el manejo clínico de los pacientes.

Comorbidity between Axis I mental disorders and substance use disorders range from 5%--60% (Farrell, 1998; Fowler, 1998). It has been suggested that dually diagnosed patients are inadequately treated for both disorders and that they are problematic from a diagnostic, clinical management and economic perspective. Dual Diagnosis (DD) maybe associated with a number of issues including increased aggression, increased non-compliance with medication (Swartz, 1998), and exacerbated psychopathology (Tomasson, 1997). However, contradictory evidence has also been found (Leon, 1998), which suggests that patients with DD may be a higher functioning population of mentally ill patients. The objectives of the present study were to determine the prevalence and clinical characteristics of dual diagnosis patients in a chronic psychiatric population. A sample of 217 patients with schizophrenia spectrum disorders was randomly sampled from the psychiatric facilities of the Montreal General Hospital. Almost half of the sample presented with comorbid addictive disorders; the most common drugs abused were alcohol, cannabis and cocaine. Those patients who had a lifetime diagnosis of substance abuse or dependence were more likely to be male, had a more severe course of psychiatric illness, higher rates of psychiatric symptomology, were more likely to be tobacco smokers and had higher rates of non-compliance with psychiatric medications. Further analyses revealed lower levels of social support and more legal problems in patients with DD, all of which may negatively impact on the quality of care for dual diagnosis patients in the clinical setting.

Dual Diagnosis (DD) refers to the co-existence of a Severe Mental Illness (SMI) and a Substance Use Disorder (SUD) in the same individual. The comorbid prevalence of these two diagnoses is very common, with Schizophrenia (SZ), Bipolar Disorder (BD), and Major Depressive Disorder (MDD) as the three most prevalent SMI among patients with SUD. The co-existence of SUD and these SMIs includes several clinical characteristics, related to evolution and prognosis, which may complicate a patient`s recovery from both disorders. However, nowadays there is an evident need to carry out studies that provide both theoretical and practical knowledge transferable to the clinical management of patients with DD. The present study aimed, as the first objective, to study personality characteristics in a sample of patients with SUD taking into account their comorbid SMI. We evaluated a sample of 104 male patients undergoing SUD treatment, considered in three groups according to the comorbid SMI: SZ+ Group (SUD and SZ; N=37), BD+ Group (SUD and BD, N=32), and MDD+ Group (SUD and MDD; N=35). Two instruments were used to measure personality, the Cloninger's Temperament and Character Inventory-Revised (TCI-R) and the Zuckerman-Kuhlman Personality Questionnarie (ZKPQ), both based on psychobiological models. In addition, we explored the influence of the SMI in the relationship among personality and clinical variables related to both SUD and SMI diagnoses. Our second objective was to explore the influence of DD in the coping strategies used in relation to addiction treatment. SUD treatment represents a challenging situation for all patients, but given DD clinical complications, we studied the possible differential profile in the coping strategies used between patients with SZ+ (the most prevalent diagnosis in our sample) and SUD only. To elucidate the influence of comorbidity, a sample of 89 male patients undergoing treatment for addiction was included and distributed in two groups: SZ+ Group (SUD and SZ; N=39) and SUD Group (SUD only; N=43); these patients were assessed using the Coping Strategies Inventory (CS) from Tobin and completed an exhaustive clinical evaluation as well. The main personality results indicate that patients with SZ+ are characterized by an increased anxiety and fear of uncertainty (high Harm Avoidance from the TCI-R), difficulties in persevering when facing frustration and fatigue (lower Persistence from TCI-R), and the preference for solitary activities or small groups (lower Sociability from ZKPQ). Our findings suggest that patients with SZ+ are the ones who would especially need strategies to manage negative expectations and anxiety, motivational strategies, and if possible, a gradual incorporation to the group therapy sessions used during SUD treatment. Regarding personality characteristics for patients with BD+, these are characterized by an exploratory activity in response to novel stimulation, being more impulsive, getting easily bored, and by the willingness to experiment strong emotions for the sake of these types of experiences (high Novelty Seeking from the TCI-R and Impulsivity- Sensation Seeking from the ZKPQ). In addition, BD+ diagnosis is highlighted by a higher level of worries, fears, tension, and general emotional upset (high Neuroticism-Anxiety from the ZKPQ). Therefore, patients with BD+ are the ones who would require a therapeutic approach which emphasizes impulsivity management, as well as, achieving the general activity and stimulation they require. Finally, considering patients with MDD+, these are characterized by being more pragmatic, realistic, having an unstable self-image, and an erratic world-view (lower Self-transcendence from the TCI-R). Taking also into account that in previous studies a lower Self-transcendence is linked to worse general well-being and dropping-out SUD treatment, it may be suggested that interventions with MDD+ patients could benefit from therapeutic strategies that aim to increase creativity and spirituality, which are both associated with a higher Self-transcendence. With regards to the main relationships founded among personality and SUD and SMI clinical variables, we observed that such relationships are also influenced by the type of comorbid SMI. Results from the TCI-R indicate that higher scores in Novelty Seeking for patients with BD+ are related to a higher severity of addiction. Harm Avoidance is only linked to clinical variables for patients with SZ+, with a higher Harm Avoidance in patients having a greater presence of negative symptoms and general psychopathology. While Persistence did not show any clinical implications for none of the groups, Self- transcendence only showed clinical implications for the MDD+ group, in which a later age of SUD onset is associated with a lower Self-transcendence. Regarding results from the ZKPQ, we observed a positive relationship between Neuroticism-Anxiety and manic symptoms for patients with BD+, and the number of suicide attempts for patients with SZ+. Lastly, a higher Sociability is related to a later age of SUD onset for patients with SZ+, and to a later age of SMI onset for patients with MDD+. The study about coping strategies using the CSI in patients with SZ+, revealed that they are less likely to employ Engagement Strategies (Problem Solving and Social Support) and they have a lower self-perceived capacity to cope with treatment, compared with patients with SUD only. Among patients with SZ+, a major use of the Problem Solving strategy is related to a later age of SUD onset, and the self-perceived capacity to cope with treatment is negatively linked to severity of addiction and to positive symptoms. According to normative data, both groups (SUD and SZ+) use the Disengagement Strategy of Self-Criticism frequently; although the use of Self-Criticism was lower for patients with SZ+. Additionally, a higher use of Self-Criticism is related to a higher daily amount of medications for the SZ+ group. Hence, the presence of DD is associated with a lower use of active coping strategies and points to the need of training problem solving strategies, as well as, abilities to seek for social support during SUD treatment of patients with SZ+. Working on these two strategies could potentially improve treatment adherence and therapeutic outcomes. In conclusion, the findings of this thesis showed that patients with DD have different personality characteristics depending on their comorbid SMI diagnosis. Moreover, the relationship among personality and SUD and SMI clinical variables is also influenced by the type of SMI. Our findings extend to the DD field previous data about personality dimensions as potential endophenotypes for SZ (high Harm Avoidance) and BD (high impulsivity). Likewise, we observed the potential endophenotypes for developing an addiction (high Novelty Seeking and Impulsivity-Sensation Seeking, which are suggested especially for alcohol SUD) in polydrug users, regardless of the main SUD´s substance and adding nuances according to the comorbid SMI. On the other hand, a lower use of active coping strategies in relation to addiction treatment for patients with SZ+ extends to the DD field previous observations done in patients with SUD only and with SZ. Our data point to the potential usefulness of working different aspects, related to personality and coping, during DD treatment considering the comorbid SMI. However, future research is needed to advance in those lines of research, as well as, to overcome the limitations of our work. Additional studies should include a clinical, personality, and coping assessment, and longitudinal measures combined with objective data such as genetic polymorphisms and functional neuroimaging.
El concepto de Patología Dual (PD) hace referencia a la concurrencia de un Trastorno Mental (TM) y un Trastorno por Uso de Sustancias (TUS) en una misma persona. La prevalencia conjunta de estos dos diagnósticos es muy frecuente, siendo los tres TM severos comórbidos más prevalentes en pacientes con TUS la Esquizofrenia (SZ), el Trastorno Bipolar (TB) y el Trastorno Depresivo Mayor (TDM). La coexistencia del TUS y estos TMs conlleva una serie de características clínicas, de evolución y pronóstico, que dificultan la recuperación del paciente en ambos trastornos. Sin embargo, en la actualidad existe una necesidad evidente de realizar estudios que aporten tanto conocimiento teórico como trasladable al manejo clínico de los pacientes con PD. El presente trabajo se propuso, como primer objetivo, estudiar las características de personalidad en una muestra de pacientes con TUS atendiendo al diagnóstico de TM severo comórbido. Evaluamos una muestra de 104 pacientes hombres en tratamiento para el TUS, considerados en tres grupos según el diagnóstico de TM severo comórbido: Grupo SZ+ (TUS y SZ; N=37), Grupo TB+ (TUS y TB; N=32) y Grupo TDM+ (TUS y TDM; N=35). Se utilizaron dos instrumentos de medición de la personalidad, el Temperament and Character Inventory-Revised (TCI-R) de Cloninger y el Zuckerman-Kuhlman Personality Questionnarie (ZKPQ), ambos basados en modelos psicobiológicos. Además, se exploró la influencia del TM en la relación entre personalidad y variables clínicas tanto del TUS como del TM. Nuestro segundo objetivo consistió en explorar la influencia de la PD en las estrategias de afrontamiento utilizadas en relación al tratamiento de la adicción. El tratamiento para el TUS representa un desafío para todos los pacientes, pero dadas las complicaciones clínicas de la PD se estudió el posible perfil diferencial de las estrategias de afrontamiento entre pacientes con SZ+ (diagnóstico más prevalente en nuestra muestra) y con sólo TUS. Para elucidar la influencia de la comorbilidad, se incluyó una muestra de 89 pacientes hombres en tratamiento para la adicción considerados en dos grupos: Grupo SZ+ (TUS y SZ; N=39) y Grupo TUS (N=43), a quienes se les aplicó el Coping Strategies Inventory (CSI) de Tobin junto con una exhaustiva evaluación clínica. Los principales resultados sobre personalidad indican que los pacientes con SZ+ destacan por una mayor ansiedad y temor a la incertidumbre (elevada Evitación del Riesgo del TCI-R), dificultad para perseverar ante la frustración y la fatiga (menor Persistencia del TCI-R) y preferencia por actividades en solitario o en grupos pequeños (menor Sociabilidad del ZKPQ). Nuestros hallazgos sugieren que los pacientes con SZ+ son quienes necesitarían especialmente de estrategias de manejo de expectativas negativas y ansiedad, de estrategias motivacionales y, siempre que sea posible, una incorporación paulatina a las sesiones grupales utilizadas durante el tratamiento para el TUS. Respecto a las características de personalidad de los pacientes con TB+, éstos destacan por la excitación frente a estímulos novedosos, ser más impulsivos, aburrirse fácilmente y poseer una necesidad de experimentar sensaciones fuertes por el mero hecho de vivirlas (elevadas Búsqueda de Novedad del TCI- R e Impulsividad-Búsqueda de Sensaciones del ZKPQ). Además, el diagnóstico de TB+ destaca por un mayor nivel de preocupaciones, miedos, tensión y malestar general (elevado Neuroticismo-Ansiedad del ZKPQ). Por tanto, serían especialmente los pacientes con TB+ quienes requieren de un énfasis terapéutico en el manejo de la impulsividad y en la búsqueda de la activación y estimulación que necesitan. Finalmente atendiendo a pacientes con TDM+, éstos se caracterizan por ser más pragmáticos, realistas, poseer una imagen más inestable de sí mismos y una visión más errática del mundo (menor Trascendencia del TCI-R). Considerando además que en estudios previos se ha relacionado una menor Trascendencia con peor bienestar general y con el abandono del tratamiento para el TUS, cabe sugerir que las intervenciones con estos pacientes se podrían beneficiar de incluir estrategias terapéuticas que incrementen la creatividad y la espiritualidad, ambas asociadas a una mayor Trascendencia. Respecto a las principales relaciones encontradas entre personalidad y variables clínicas del TUS y del TM, observamos que éstas también se hallan influenciadas por el tipo de TM severo comórbido. Los resultados del TCI-R indican que las puntuaciones superiores en Búsqueda de Novedad de los pacientes con TB+ se asocian a una mayor gravedad de la adicción. La Evitación del Riesgo sólo se relacionó con variables clínicas en pacientes con SZ+, siendo ésta más elevada cuanto mayor es la presencia de síntomas psicóticos negativos y de psicopatología general. Mientras que la Persistencia no mostró relaciones con variables clínicas en ningún grupo, la Trascendencia sólo mostró implicaciones clínicas en el grupo con TDM+, en el cual, una mayor edad de inicio del TUS se asoció a una menor Trascendencia. Respecto a los datos aportados por el ZKPQ, observamos una relación positiva entre el Neuroticismo-Ansiedad y la presencia de síntomas maníacos en pacientes con TB+, así como con la cantidad de intentos de suicidio en pacientes con SZ+. Finalmente, una mayor Sociabilidad se relaciona con una edad más tardía de inicio del TUS en pacientes con SZ+ y de inicio del TM en pacientes con TDM+. El estudio de estrategias de afrontamiento mediante el CSI en pacientes con SZ+ mostró que éstos utilizan con menor frecuencia estrategias de Manejo Adecuado del problema (Resolución de Problemas y Apoyo Social), y perciben que tienen menor capacidad para afrontar el tratamiento respecto a pacientes con sólo TUS. En pacientes con SZ+ un mayor uso de la estrategia de Resolución de Problemas se relaciona con una edad de inicio de TUS más tardía, y la capacidad para afrontar el tratamiento se asocia negativamente a la gravedad de la adicción y a los síntomas psicóticos positivos. Según baremos normativos ambos grupos (TUS y SZ+) recurrían muy frecuentemente a la estrategia de Manejo Inadecuado de Autocrítica, aunque su uso era menor en pacientes con SZ+. Además, una mayor Autocrítica se relaciona con más cantidad diaria de medicación en SZ+. Por tanto, la presencia de PD se vincula a un afrontamiento del tratamiento para la adicción menos activo y apunta a la necesidad de entrenar a los pacientes con SZ+ en el uso de estrategias de resolución de problemas y búsqueda de apoyo social durante su tratamiento para el TUS, pudiendo ello mejorar tanto la adherencia como la respuesta terapéutica. Como conclusión, los hallazgos de esta tesis muestran que los pacientes con PD difieren en las características de personalidad según su diagnóstico de TM severo comórbido. Además, la relación entre la personalidad y las variables clínicas del TUS y TM también se halla modulada por el tipo de TM. Nuestros resultados extienden al ámbito de la PD los datos previos sobre dimensiones de personalidad como posibles endofenotipos de la SZ (elevada Evitación del Riesgo) y del TB (elevada impulsividad). Así mismo, los posibles endofenotipos de personalidad para el desarrollo de la adicción (elevadas Búsqueda de Novedad e Impulsividad-Búsqueda de Sensaciones, que se sugieren especialmente para el TUS por alcohol) los observamos en pacientes policonsumidores, con independencia del tipo de sustancia principal del TUS, añadiendo matices según el TM severo comórbido. Por otra parte, el menor uso de estrategias de afrontamiento activas en relación al tratamiento de la adicción en pacientes con SZ+ extiende al ámbito de la PD observaciones previas realizadas en pacientes con TUS y con SZ. Los datos apuntan a la posible utilidad de trabajar aspectos diferenciales, relacionados con la personalidad y el afrontamiento, durante el tratamiento de la PD atendiendo al TM severo comórbido. Sin embargo, para poder progresar en esta área y superar las limitaciones de nuestros estudios, se requieren futuras investigaciones que, junto con la evaluación clínica, de personalidad y afrontamiento, incluyan registros longitudinales y medidas objetivas como polimorfismos genéticos y de neuroimagen funcional.

The goal of this study was to determine the bio-psychosocial treatment needs of dual diagnosis patients with depressive episodes and alcohol misuse. In order to achieve this goal, a qualitative research approach was adopted to gain a holistic understanding of dual diagnosis, as well as to explore and to describe the bio-psychosocial treatment needs of these individuals. This research study aimed to contribute towards solving a practical problem in practice by offering recommendations for a multidisciplinary team approach with regard to the treatment of patients diagnosed with depressive episodes and alcohol misuse in South African treatment centres. To this end, the collective case study design guided the research study. A two-stage sampling strategy was implemented in the study. Firstly, purposive sampling was used to identify potential participants, and it was followed up with, secondly, volunteer sampling to recruit 10 individuals with co-occurring depressive episodes and alcohol misuse from a private psychiatric clinic in Pretoria, which formed the research sample. Furthermore, a semi-structured one-on-one interview, guided by questions contained in an interview schedule, was used as a data collection method. The researcher implemented the qualitative data analysis process of Creswell (1998, in Schurink, Fouché & De Vos, 2011) to extrapolate themes and sub-themes from the raw data through thematic analysis. The trustworthiness of the data interpretation was confirmed through peer debriefing, member checking, as well as the assurance of confidentiality. An analysis of two different sources of data, namely the literature review and interviews, was used to answer the following research question: What are the bio-psychosocial treatment needs of dual diagnosis patients suffering from depressive episodes and alcohol misuse? The key findings indicated that persons suffering from a dual diagnosis of depressive episodes and alcohol misuse have idiosyncratic biological, psychological and social treatment needs. On a biological level it was found that patients with a dual diagnosis lead a less active and an unhealthy lifestyle and are therefore more prone to the development of chronic illnesses, such as hypertension and cardiovascular disease. It was also found that these individuals exhibit addictive behaviours apart from the alcohol misuse. With regard to psychological needs, the research found that dual diagnosis patients experience difficulties in expressing their needs and emotions to others. In this regard the research indicated that these individuals have poorly developed coping mechanisms and limited resources for gaining an improved sense of well-being. Identified areas in which these individuals may need assistance on a psychological level include: general coping mechanisms, communication skills, problem solving skills, and conflict management. With regard to violent and aggressive behaviour, it was found that these individuals are more likely to internalise their frustration and aggress towards themselves. On a social level it was found that individuals with a dual diagnosis of depressive episodes and alcohol misuse experience more relationship breakdown and less social support. Additionally, on a social level these individuals experience difficulties in coping in the workplace, as well as having problems with financial management. It is recommended that the multidisciplinary team participate in the development of psycho-educational groups that focus on the education of dual diagnosis patients regarding their needs on each level of functioning. Furthermore, it is recommended that effective clinical communication patterns are in place to prevent fragmented service delivery to individuals with a dual diagnosis. It is recommended that service delivery takes place in all forms of service delivery, including individual therapy, psycho-educational groups, group work activities, as well as family counselling. Further research could focus on the following: 1) Extending the research population to areas outside the Gauteng Province, or even South Africa, in order to determine if these findings can be generalised to all patients with a dual diagnosis of depressive episodes and alcohol misuse; 2) Conducting the research in public health care centres to determine if the findings of this study are also prevalent in lower socio-economic classes (taking into consideration that the present study was conducted at a private psychiatric clinic); 3) Repeating the study with different combinations of psychiatric illnesses, as well as substances of abuse, to determine if the conclusions drawn from this study can be made applicable to dual diagnosis in general, or only to dual diagnosis with depressive episodes and alcohol misuse in particular.
Dissertation (MSW)--University of Pretoria, 2014.
tm2015
Social Work and Criminology
MSW
Unrestricted

This study explores the dual diagnosis substance abuse phenomenon within the context of Vancouver area mental health boarding homes. The target population consisted of thirty-nine mental health boarding homes used by Greater Vancouver Mental Health Services, Mental Health Residental Services. An attempt was made to survey directors (n=37), staff (n=unknown), and residents (n = 422), to: estimate the prevalence of dual diagnosis substance abuse within these homes; look for associations between substance use/abuse and the demographic characteristics of staff, directors, and residents; examine boarding home policies; and to establish what, if any, services should be developed. Questionnaires were completed by twenty-nine directors (78%), twenty staff members (% unknown), and ten residents (3%), from twenty-nine boarding homes with a total resident population of 358. Results indicated that one hundred and fifteen residents (32%) consumed alcohol, and 57 residents (16%) had consumed alcohol during a specified two week period. Only eight residents (2%) out of a potential 358 (from four different facilities) reportedly had substance related problems during the specified two week period. However, substance abuse was identified in eleven facilities (38%), without referrence to the two week time limitation. Further, staff and directors from fifteen facilities (52%) had at some time tried to get help for a resident with a substance abuse problem. Thus, while very few residents reportedly had dual diagnosis substance abuse problems, a considerably greater number of boarding homes reportedly had problems related to dual diagnosis substance abuse. Twenty-four directors (86%) and thirteen staff (68%) were interested in receiving a workshop on dual diagnosis substance abuse. It is the recommendation of this author that a drug education program/workshop for boarding home directors and staff be developed through the Greater Vancouver Mental Health Services "dual diagnosis program."
Arts, Faculty of
Social Work, School of
Graduate

Part 1: Literature review. This review of the published literature examines the consequences for individuals with co-occurring substance use disorder and chronic mental illness in traditional treatment systems that provide separate mental health and substance use treatment and identifies barriers to effective service delivery. Barriers to effective assessment and treatment are related to a lack of integration of treatments, a Jack of networking among services, and a failure to identify and assess adequately for the presence of a dual disorder. The attitude of professionals towards DD individuals is indicated as a potential barrier. Professional education in dual disorders is emphasized and recommendations from the literature are discussed. Part 2: Research report. This study was undertaken to examine the attitudes and practice of psychologists towards patients with dual disorders, and to establish whether the acquisition of additional education in dual diagnosis made a difference regarding assessment and treatment. An 18-item questionnaire was developed and mailed to 200 registered psychologists throughout Australia. A total of 98 responded after receiving two reminder letters. Results of univariate tests and discriminant function analysis indicated that education in dual diagnosis was significantly related to better knowledge of, and practice by psychologists towards, dually disordered patients. These findings were significantly related to the successful identification of individuals with a dual disorder as well as effective assessment and treatment.

BACKGROUND: Methamphetamine (MA) use disorder in individuals with severe mental disorders (SMDs) has significant impact on clinical presentation and care. Although treatments exist, these are met by significant challenges. Notably, brief treatments for MA use within the general population have been feasible, acceptable and effective. An individualized, integrated treatment for MA use within a psychiatric inpatient setting would allow adjustment of the treatment according to individual patient needs. It is important to understand the patient needs and potential service barriers to care before formulating a treatment. This study begins to address this gap by seeking to understand the views of healthcare providers on a brief treatment to address MA use among patients with a dual diagnosis. METHODS: Thirteen key stakeholders working with patients with mental disorders including severe mental disorders and co morbid MA use were interviewed using an open-ended semi- structured interview schedule designed to explore their views on a brief treatment for MA use among patients with a dual diagnosis. Interviews were transcribed and the framework approach was used to conduct data analysis. RESULTS: Numerous themes emerged from the data. First, there are multiple risk factors for MA use. Second, this use has a significant impact on multiple aspects of patient presentation and care including individual impacts, family impacts, and impact on care. Third, although treatments for MA use disorders exist, these have significant challenges at multiple levels. Lastly, the integration of a modified brief treatment for MA use in patients with dual diagnosis would be possible if it was adjusted to patient-specific needs within the existing system and if the team adapting the treatment were cognizant of existing and potential challenges. CONCLUSIONS: The adaptation and integration of a brief treatment for MA use among patients with severe mental disorders was considered possible and even necessary if existing and potential challenges were carefully addressed.

Sleep is a critical part of the individual's daily performance and survival that is part of the primary sleep-wake circadian rhythm. Any sleep disturbance causes damage to wakefulness (fatigue, drowsiness) and can even lead to various health problems. The alteration of the circadian rhythm affects the quality of sleep, decreases the quality of life (QOL) and can motivate the development of various medical, neurological and mental pathologies such as major depressive disorder (MDD) and substance use disorder (SUD) The relationship between social time and endogenous rhythms is an individual difference called chronotype that classifies individuals into morning type, intermediate or no type, and evening type. There are numerous studies that point to the evening type as a risk factor for developing maladaptive behaviors, sleep disorders, psychiatric symptoms and mental disorders, among which SUD and MDD stand out. Substance use and sleep problems are mutual and feed off each other. Substance use influences sleep with detrimental effects, and the presence of a sleep problem can promote substance use as an attempt at self-medication. Although the available evidence on circadian rhythm, chronotype and SUD in the Iranian population is very limited, existing studies indicate a high prevalence of self-medication with the risk of entering a vicious cycle and developing both SUD and a more serious sleep problem. Substance use can also cause mental illness and vice versa. The presence of a mental disorder comorbid with SUD, which we refer to as dual pathology (DP), implies more clinical (hospitalizations, suicide attempt, relapses) and social problems compared to the presence of a single disorder. However, there is little research in this area and even less in the study of the affectation of circadian rhythmicity and QOL in patients with DP. The general objective of this study was to investigate the clinical characteristics and differences, circadian functioning and QOL in a sample of 238 Iranian male patients (38.14 ± 10.11 years) under treatment with a diagnosis of SUD (N = 81 ), with SUD and comorbid schizophrenia (SUD + SZ; N = 75) and with SUD and comorbid major depressive disorder (SUD + MDD; N = 82). Another objective was to create the Persian version of the Sleep Belief Scale (SBS) and explore its psychometric properties in the sample of patients studied. The history and presence of clinical symptoms were assessed together with circadian functioning, using various standardized instruments [hourly parameters for social jet-lag (SJL), the reduced morning-evening questionnaire (rMEQ), the Pittsburgh sleep quality index (PSQI) and SBS]. For QOL the scale developed by the World Health Organization (WHOQOL-BREF) was used. This study is the first investigation with clinical diagnoses and selected measurements developed in Iran. According to the sociodemographic and clinical variables, the SUD + SZ patients were much younger single people, with a higher number of substance use and an earlier age of onset of SUD compared to the other two groups. In the SUD + MDD group, there was more concomitance of organic pathology, a greater number of antecedents of psychiatric disorders and suicide attempts, as well as more illiterate individuals. SUD patients contributed the highest proportion of opium and crystal users. Both the SUD and SUD + SZ groups had a higher proportion of heroin users and polydrug users. Regarding sleep characteristics, although no differences were observed between the groups in the SJL, the SUD patients tended to go to bed later than the DP groups both during working days and on days off (weekend ) together with a greater presence of IT. In contrast, patients with SUD + MDD were more prone to the morning type and patients with SUD + SZ to the evening type. In the total sample of our study, the evening patients were those who showed the highest rate of polydrug users. The SUD + MDD group had the worst PSQI scores, even after controlling for age and age of onset of SUD, in addition to showing a greater number of drug prescriptions for sleep. In contrast, the SUD + SZ group was the one that showed the worst scores in the sleep disturbance parameter of the three. The age of onset of SUD and the severity of MDD showed a negative and positive relationship, respectively, with the total scores of the PSQI. Furthermore, since we did not find any interaction between the chronotype and the groups with respect to sleep quality, once the mental disorder has developed, it and its severity seem to be the best indicators of sleep disturbances, regardless of the patient's chronotype . The SBS in its original form did not show adequate psychometric properties in the patient sample, with unweighted items in any dimension and an internal reliability of less than 0.700. A reduced version with 13 items was created, which meets the minimum reliability criteria and requires less response time. The analyzes carried out with both the original proposal and our reduced one provided better scores for the SUD and SUD+MDD groups in both cases compared to the SUD + SZ group. This study highlights that a higher number of substance use and the greater severity of SZ or MDD are linked to poorer scores on the SBS, both on the original scale and on the reduced scale. Taking into account the dimensions of SBS (original and reduced), the severity of SZ was negatively related to the scores of Behaviors incompatible with sleep and Thoughts and attitudes towards sleep, while the number of substance use was negatively associated with the scores. Behaviors incompatible with sleep. In addition, in the SUD + MDD group, lower scores in Thoughts and attitudes towards sleep were related to a higher number of substance use, a lower age of onset of SUD and greater severity of MDD. The SUD group provided a better QOL than the DP groups in all dimensions, even after controlling for confounding factors. Except for Environmental Health in the SUD group, all QOL scores in the three groups were lower than the normative data for the healthy population. In the total sample, we found that the number of substance use was negatively related to the overall QOL score. In the SUD + SZ group, more suicide attempts and more SJL were associated with less Physical Health and Social Relationship. On the other hand, in the SUD + MDD group, the higher the SJL and the severity of MDD, the worse physical health was observed and the lower sleep latency was related to more mental health. Our results indicate that DP patients in most clinical and circadian characteristics –with an emphasis on sleep-, as well as QOL suffer more problems compared to patients with SUD. This highlights the importance of caring for these patients in treatment centers for those variables that may be modified during the therapeutic process. Future studies may consider our results for the promotion of knowledge in this area, with the aim of better understanding the associations between variables and overcoming the limitations of the present work with the ultimate aim of designing better and more effective treatments.
El sueño es una parte fundamental del desempeño diario y la supervivencia del individuo que forma parte del ritmo circadiano principal de sueño-vigilia. Cualquier alteración del sueño provoca un perjuicio para la vigilia (fatiga, somnolencia) e incluso puede derivar en diversos problemas de salud. La alteración del ritmo circadiano afecta la calidad del sueño, disminuye la calidad de vida (CV) y puede motivar el desarrollo de diversas patologías médicas, neurológicas y mentales como el trastorno depresivo mayor (TDM) y el trastorno por uso de sustancias (TUS). La relación entre el tiempo social y los ritmos endógenos es una diferencia individual denominada cronotipo que clasifica a los individuos en tipo matutino, intermedio o ningún tipo y tipo vespertino. Existen numerosos estudios que apuntan al tipo vespertino como factor de riesgo para desarrollar conductas inadaptadas, trastornos del sueño, síntomas psiquiátricos y trastornos mentales, entre los que destacan el TUS y el TDM. El uso de sustancias y los problemas de sueño son mutuos y se retroalimentan. El uso de sustancias influye en el sueño con efectos perjudiciales y la presencia de un problema de sueño puede promover el consumo de sustancias como un intento de automedicación. Aunque la evidencia disponible sobre ritmo circadiano, cronotipo y TUS en la población iraní es muy limitada, los estudios existentes indican una alta prevalencia de automedicación con el riesgo de entrar en un círculo vicioso y desarrollar tanto TUS como un problema de sueño más graves. El uso de sustancias también puede causar enfermedades mentales y viceversa. La presencia de un trastorno mental comórbido con TUS, al que nos referimos como patología dual (PD), implica más problemas clínicos (hospitalizaciones, intento de suicidio, recaídas) y sociales en comparación con la presencia de un solo trastorno. Sin embargo, hay poca investigación en esta área y menos todavía en el estudio de la afectación de la ritmicidad circadiana y la CV de los pacientes con PD. El objetivo general de este estudio fue el de investigar las características y diferencias clínicas, el funcionamiento circadiano y la CV en una muestra de 238 pacientes varones iraníes (38,14 ± 10,11 años) en tratamiento con diagnóstico de TUS (N = 81), con TUS y esquizofrenia comórbida (TUS+SZ; N = 75) y con TUS y trastorno depresivo mayor comórbido (TUS+TDM; N = 82). Otro objetivo fue crear la versión persa de la Sleep Belief Scale (SBS) y explorar sus propiedades psicométricas en la muestra de pacientes estudiados. El historial y la presencia de síntomas clínicos se evaluaron junto con el funcionamiento circadiano, mediante diversos instrumentos estandarizados [parámetros horarios para el jet-lag social (JLS), el cuestionario reducido de matutinidad-vespertinidad (rMEQ), el índice de calidad del sueño de Pittsburgh (PSQI) y la SBS]. Para la CV se utilizó la escala desarrollada por la Organización Mundial de la Salud (WHOQOL- BREF). Este estudio es la primera investigación con los diagnósticos clínicos y mediciones seleccionadas desarrollado en Irán. Según las variables sociodemográficas y clínicas, los pacientes TUS+SZ eran personas solteras mucho más jóvenes, con un mayor número de consumo de sustancias y una edad más temprana de inicio del TUS en comparación a los otros dos grupos. En el grupo SUD+TDM se observó más concomitancia de patología orgánica, una mayor cantidad de antecedentes de trastornos psiquiátricos e intentos de suicidio, así como más individuos analfabetos. Los pacientes TUS aportaron la mayor proporción de consumidores de opio y cristal, mientras que los SUD+SZ mostraron la tasa más alta de número de sustancias consumidas. Tanto el grupo SUD como el SUD+SZ tenían una mayor proporción de consumidores de heroína y de policonsumidores. En cuanto a las características del sueño, si bien no se observaron diferencias entre los grupos en el JLS, los pacientes TUS tendían a una hora más tardía de acostarse que los grupos PD tanto durante los días laborales como en los días libres (fin de semana) junto a una mayor presencia del TI. En cambio, los pacientes con TUS+TDM eran más propensos al tipo matutino y los pacientes con TUS+SZ al tipo vespertino. En la muestra total de nuestro estudio, los pacientes vespertinos fueron los que mostraron la tasa más alta de policonsumidores. El grupo TUS+TDM aportó las peores puntuaciones del PSQI, incluso después de controlar la edad y la edad de inicio del TUS, además de mostrar una mayor cantidad de prescripciones farmacológicas para dormir. En cambio, el grupo SUD+SZ fue de los tres el que mostró las peores puntuaciones en el parámetro de alteración del sueño. La edad de inicio del TUS y la gravedad del TDM mostraron una relación negativa y positiva, respectivamente, con las puntuaciones totales del PSQI. Además, dado que no encontramos ninguna interacción entre la cronotipo y los grupos con respecto a la calidad del sueño, una vez desarrollado el trastorno mental éste y su severidad parecen ser los mejores indicadores de las alteraciones del sueño, con independencia de la cronotipo del paciente. La SBS en su forma original no mostró unas propiedades psicométricas adecuadas en la muestra de pacientes, con ítems sin ponderar en ninguna dimensión y una fiabilidad interna inferior a 0,700. Se creó una versión reducida con 13 ítems, que cumple con el mínimo criterio de fiabilidad y requiere menor tiempo de respuesta. Los análisis realizados tanto con la propuesta original como con la nuestra reducida aportaron en ambos casos mejores puntuaciones de los grupos TUS y TUS+TDM en comparación con el grupo TUS+SZ. Este estudio destaca que un mayor número de uso de sustancias y la mayor gravedad de SZ o MDD se vinculan a peores puntuaciones en la SBS, tanto en la escala original como en la reducida. Teniendo en cuenta las dimensiones de SBS (original y reducida), la gravedad de SZ se relacionó negativamente con las puntuaciones de Comportamientos incompatibles con el sueño y Pensamientos y actitudes hacia el sueño, mientras que el número de consumo de sustancias se asoció negativamente con los Comportamientos incompatibles con el sueño. Además, en el grupo TUS+TDM las puntuaciones más bajas en Pensamientos y actitudes hacia el sueño se relacionaron con un mayor número de consumo de sustancias, menor edad de inicio del TUS y mayor gravedad del TDM. El grupo SUD aportó una mejor CV que los grupos con PD en todas las dimensiones, incluso tras controlar los factores de confusión. A excepción de la Salud ambiental en el grupo TUS, todas las puntuaciones de CV en los tres grupos fueron inferiores a los datos normativos de la población sana. En la muestra total, encontramos que el número de consumo de sustancias se relacionó negativamente con la puntuación general de CV. En el grupo TUS+SZ, más intentos de suicidio y más SJL se asociaron a una menos Salud física y Relación social. En cambio, en el grupo TUS+TDM, a mayor JLS y gravedad del TDM se observó peor Salud física y la menor latencia del sueño se relacionaba con más Salud psíquica. Nuestros resultados indican que los pacientes con PD en la mayoría de las características clínicas y circadianas –con énfasis en el sueño-, así como la CV sufren más problemas en comparación con los pacientes con TUS. Ello resalta la importancia de la atención a estos pacientes en los centros de tratamiento de aquellas variables que puedan ser modificadas durante el proceso terapéutico. Los estudios futuros pueden considerar nuestros resultados para la promoción del conocimiento en este ámbito, con el objetivo de comprender mejor las asociaciones entre variables y superar las limitaciones del presente trabajo con la finalidad última de diseñar tratamientos mejores y más efectivos.

This chapter explores the challenge of working with patients with Non-Epileptic Seizures (NES), which starts with the very name—what to call it, whether it is reasonable to call a condition by what it is not. More challenging is when and if the patient has comorbid epilepsy. The next task is to inform the patient. Working in a tertiary hospital means that the majority of patients have already seen various specialists and the idea might not be completely new to them. However, this does not make the task any easier. If possible, having both the Psychiatrist and the Neurologist together to discuss the diagnosis for the first time can help. Often, the patients are astonished when a Psychiatrist talks to them about “stress seizures,” and they respond with, “But I am not stressed.” Of course, many patients cannot express their anxiety and transform it instead, hence their physical symptoms arise, which in this case are seizures. The saga of NES continues when the focus moves on to treatment, as many times patients need time to come to terms with the very first step of accepting the diagnosis.

In this chapter we demonstrate how older adults can benefit from novel technologies. One hundred and fourteen patients with MCI according to the revised Petersen criteria (Petersen, 2006), aged between 65 and 88 years, were recruited to participate in a Serious Game training (SG) and an Active Control group (AC). They benefited from neuropsychological testing and electroencephalography before and after the intervention. Our results showed that the SG group improved performance in specific cognitive functions such as working memory, dual task performance and visual conjunction search. The performance improvement was also supported only at the SG group by increased amplitude of the Event Related Potentials extracted from the electroencephalography measures.The results from our study suggest that older adults do not need to be technologically savvy to benefit from virtual reality training.

Carotid sinus syndrome (CSS) accounts for 9% of patients presenting with syncope unexplained by the initial evaluation. It is often not considered as a possible diagnosis which can only be made by carotid sinus massage (CSM) when cardioinhibition and vasodepression occur with reproduction of symptoms. CSS must not be confused with carotid sinus hypersensitivity which is where CSM is positive in a subject without symptoms. Cardioinhibitory CSS is well treated by dual-chamber pacing but recurrence of syncope is more frequent if tilt testing is positive. Vasodepressor CSS is treated by fluids, salt, and reduction of hypotensive medication.

This chapter examines the ethical issues related to the practice of health care in an environment where human rights are absent, specifically relating to the conditions for refugees and asylum seekers who arrive by sea in Australian territory. The ethical considerations of working within the offshore detention environment are discussed. Health-care workers in these harsh environments often have divided loyalties, when duties to their patients conflict with duties to their employer or to the state. The author draws on published accounts and interviews with health-care providers who have worked on Manus Island and Nauru and Christmas Island, the sites used by Australia for offshore detention of asylum seekers.

1.Objective: Dual diagnosis patients perpetrate crime more often than healthy individuals and is of great importance for forensic mental health services. However, in dual diagnosis patients, very little is known about factors explaining criminal behavior. This work aims to summarize the epidemiological and clinical approach of dual diagnosis patients, focusing on the Iberian Peninsula scope. Aditionaly, it aims to analyse the state of the art regarding associations between demographic and clinical factors and perpetration of crime in dual disorder patients. 2. Method: A non-systematic review of the literature is presented. Bibliographic selection was carried out through keyword research in MEDLINE and Google Scholar. 3. Results and conclusions: Perpetration of violence was independently associated with younger age, severity of alcohol use problems, lifetime trauma exposure, and higher manic symptom scores. The three drugs most commonly associated with the drugs–crime connection are heroin, crack and cocaine. A study conducted in penitentiary centers of the Interior in Spain found a high percentage of dual pathology (81.4%) In the portuguese largest security ward, in Coimbra, 40.5% of the sample had dual diagnosis disorders. Forensic units must take an integrated approach to addressing substance-use disorders. It is needed to consider not only the complexities of the substance misuse and the mental disorder, but also the offending behaviour that brought them into the forensic services. Also, social skills can effectively be improved in dual diagnosis patients. Further research is required to identify additional risk factors, such as individual substances of abuse, and establish a causal model leading to criminal perpetration.

Objectives: to analyze prescription pattern of clozapine in dual diagnosis (DD) inpatients' and to find out if there was any association with acute relapses either from psychiatric symptoms or from substance use disorder. Material and Methods: a retrospective study was conducted with all patients admitted at Lisbon's Psychiatric Hospital Center for psychiatric inpatient treatment during a 4 months' period. Patients with a dual diagnosis at discharge were selected and their clinical files were screened to assess sociodemographic and clinical information. Results and conclusions: from a total of 536 inpatients, 17,5% had a dual diagnosis at discharge. Most frequent substance of abuse was alcohol, followed by cannabinoids, nicotine, cocaine, and opiates. Most frequent psychiatric diagnosis associated with substance use disorder was schizophrenia (50%), depressive disorder (17%) and bipolar disorder (10,6%). Clozapine was prescribed to 22,3% patients and a statistically significant association was found between clozapine prescription and prevention of acute relapses of psychiatric symptoms in DD patients. Although there was no significant association between prescription of clozapine versus other antipsychotic drugs in preventing relapses of substance use, there was found a larger than expected number of patients in clozapine that didn't have a relapse of substance use.

Introduction. Dual diagnosis (DD) refers to the simultaneous diagnosis of a psychiatric disorder and a substance use disorder (SUD). The prevalence rate is considerably high in patients with schizophrenia and affective disorders; it predicts a more severe illness course, with decreased adherence to treatment and higher rates of hospitalization. As such, there is a growing demand for clinical guidelines and treatment consensus for these patients. In this retrospective analysis, we aimed to examine if and how prescription patterns in DD differ regarding psychiatric diagnosis and type of substance used. Methods. Data from patients with a DD diagnosis admitted at Lisbon’s Psychiatric Hospital Center from June to September 2021 was collected (n=94). Chi-square or Fisher tests were used to analyze associations between substance use and specific psychiatric disorders, along with number and class of medications prescribed. Results. Schizophrenia was the most frequent diagnosis (n=47). The most abused substances were alcohol (n=62) and cannabinoids (n=57). We found a statistically significant association between schizophrenia and cannabis misuse (p=0,006). A personality disorder diagnosis was also found to be associated to the misuse of cannabinoids (p=0,04) and cocaine (p=0,003). Finally, there was a statistically significant association between prescription of 2 or more drugs from different classes and a diagnosis of schizophrenia. No association was found between number/class of drugs, other psychiatric conditions or the type of substance misuse. Conclusion. Our study confirms well established associations between specific substance use and psychiatric conditions. However, no evidence of a specific drug prescription pattern of use in DD patient was apparent, which suggests the need for more studies on DD population and treatment outcomes.

Introduction: According to the studies, a quarter of people who drink alcohol suffer at least one depressive episode in their lifetime. It has also been found that one-third of people who suffer from depression, abusively consume psychoactive substances, such as alcohol, as a form of self-healing. Aim: In this retrospective study, we propose to statistically quantify the relationship between alcohol-related mental and behavioural illnesses and depression spectrum disorders. Method: The retrospective study was conducted on a group of hospitalized patients, between January 1st and June 30th, 2018, at "Elisabeta Doamna" Psychiatric Hospital, in Galati, Romania. For diagnosis we used the ICD-10 (The ICD-10 Classification of Mental and Behavioral Disorders. (Clinical description, diagnostic guidelines and psychometric tests, such as HAM-D (Hamilton Depression Rating Scale)), AUDIT (Alcohol Use Disorders Identification Test). Patients were selected among those who had a combination of mental and behavioural disorders due to alcohol and depressive spectrum disorders. Results: Between January 1st and June 30th, 2018, a quarter of total 6316 hospitalized patients, or 24.79% (1566 patients) were diagnosed with alcohol-related disorders, and 5.4% (341 cases) had a dual diagnosis, with alcohol-related disorders associated with depressive elements. During this 6-month period, of all cases of alcohol-related disorders, it was found that approximately 22% had a dual diagnosis, respectively, the combination of alcohol-related disorders with depressive spectrum disorders or depressive elements. Conclusions: Unfortunately, it is estimated that depression will become a secondary cause of disability worldwide after cardiovascular disease. According to the WHO (World Health Organization), this disease affects more than 320 million people worldwide, and its combination with alcohol abuse is alarming. Therefore, patients with dual diagnosis require a multidisciplinary therapeutic approach to reduce or even neutralize the adverse consequences that may occur in the psycho-social, medical, family, economic, or behavioural context.

Methods and Material: All patients admitted for inpatient treatment at Alcohol and New Addiction’s Treatment Unit from Lisbon’s Psychiatric Hospital Center, between 1st November 2021 and 30th April 2022, were selected and screened for sociodemographic and clinical characteristics (age, gender, education level, professional situation, and activity sector at admission as well as main admission diagnosis and other psychiatric comorbidities). Comparative analysis focused on patient’s work capacity was conducted between patients who had been diagnosed with an addiction disorder (AD) and patients with DD. Results and Conclusions: Our sample had 78 patients (59 male; 19 female) and an average age of 50.7 years. From those 78 patients, 31 had diagnosis of AD and 47 had DD. Most studied until the 9th grade (55%), 26% completed 12th grade and 19% had a degree. Only 27% patients were still active at admission, with 15% being with temporary incapacity certificate and most of them being unemployed (41%) or retired (17%). Most patients worked in accommodation, transportation, and food services activities (29%), construction sector (19%) and in healthcare, education, and social work activities (17%). In our sample, more than half patients (60%) had DD. The unemployment rates between patients with (40%) and without (42%) DD were similar. However, 39% of patients without DD were active while only 19% with DD were active. Also of interest was that 34% of those with DD worked in accommodation, transportation, and food services activities and 26% of those without DD worked in the construction sector. These results show that DD has a significant impact in the working capacity and suggest that there are important differences between professional activity sectors.

1. Objectives: To assess the impact of the pregnancy on dual-diagnosed women. 2. Material and methods: Non-systematic review of the literature, through research on PubMed database with the keywords “dual diagnosis”, “pregnancy” and “mental illness”. 3. Results and conclusions: Dual diagnosis refers to the co-occurrence of a mental illness and substance abuse. The mean age of diagnosis for both mental illnesses and substance abuse on women is between 25 and 34 years old, which coincides with the period when women are most likely to be pregnant. One of the existent barriers on this topic is the lack of knowledge on the part of care providers as to the difficulties and treatment needs of the dual diagnosis client, with resultant anxiety and confusion about how to intervene, the efficacy of treatments, and especially how to balance the needs of the mother and fetus. The studies on this area show that patients with a substance abuse disorder or dual diagnosis had a high-risk pregnancy and less prenatal care than those with a mental illness alone, being schizophrenia the most frequent psychiatric diagnosis. For women who are dually diagnosed, the risks inherent in each disorder are combined with the potential for greater negative impact on pregnancy and the newborn.The risks of poor prenatal care, obstetric complications, and psychosocial difficulties increase and each disorder may exacerbate the other. Early identification and treatment of psychiatric disorders in pregnancy can prevent morbidity in pregnancy and postpartum with the concomitant risks to mother and baby.

a) Objectives: This study analyses the characteristics and prevalence of psychotic disorders in patients with substance use, that needed medical and psychiatric care in a Dual Pathology Department during a 3 years period. b) Background and aims: The strong comorbidity between substance use and psychotic disorders has been deeply studied in recent literature. The aim of this study is to analyse the characteristics of the psychotic episode (primary or drug-induced), the predominant substance of use and the age of onset of consumption, as well as some sociodemographic characteristics in these patients. c) Materials and methods After a bibliographic review of recent literature, we realize a descriptive study of psychotic disorders and substance use from a total of 531 hospitalized patients during a 3 years period, using SPSS for Windows 20.0 database for statistic results. d) Results: In this study we can observe a predominant percentage of males with an average age of 36 years old, around 50% psychotic disorders out of total number of patients with a predominant type of primary psychosis and a high prevalence of cocaine (18% of total patients), alcohol (16%) and cannabis (8%) use and also an early age of onset of problematic consumption (15 years old for alcohol, 16 years old for cannabis and 21 years old for cocaine). e) Conclusions: The result of this study approach the current literature data about psychotic disorders and substance use and underlines the importance of a correct and early diagnosis in patients with a serious mental illness.

Objectives Previous studies have reported that substance misuse (including alcohol) was the strongest risk factor for violence among psychiatric diagnoses, and absolute rates of violence perpetration of over 10% in substance misuse have been found, meaning that it is an important adverse outcome for clinicians to consider. However, very few studies exist about differences in individuals considered not guilty by reason of insanity (NGRI) with only a primary psychiatric diagnosis and those with dual pathology. This study aims to compare these two groups regarding criminal history and violence. Material and Methods We analyzed a sample of 44 inpatients committed under security measure in the Forensic Psychiatry Regional Department of Lisbon’s Psychiatric Hospital Centre, after being deemed NGRI and dangerous. Data regarding previous history of substance use, psychiatric disorder and criminal history was retrospectively collected. Results and conclusions Unlike what is described in literature for other groups, in our sample of NGRI patients, dual pathology was significantly associated to having no previous violent behavior; furthermore, regarding the offense for which they were considered NGRI, patients with dual pathology were not more likely to have committed a violent crime when compared with patients with only a primary diagnosis. This may be explained because the primary illness (and not other psychosocial factors or substance misuse) was considered the primary reason for having committed the offense, and many patients were committed for domestic violence in the context of developmental disorders, an independent risk factor for violence against relatives. There was no difference between the two groups regarding other variables. Our study highlights that drug and substance misuse may be a less important factor regarding violence in the context of insanity than in other types of violence.

Goals: Non-systematic literature review of the role of aripiprazole in alleviating cocaine craving in schizophrenic patients with cocaine-dependence (CD). Material and methods: From the review performed, 2 studies outstand: In one study, 6 schizophrenic patients with CD completed 8 weeks of treatment with aripiprazole at a maximum dose of 15 mg/d. The Brief Psychiatric Rating Scale and the Brief Substance Craving Scale (BSCS) were used to measure psychosis and subjective cocaine and alcohol cravings and urine tests for cocaine were performed. In another study, 44 CD patients with schizophrenia or schizoaffective disorder were treated with aripiprazole or perphenazine during 8 weeks. The perphenazine group received the recommended dosage not exceeding 24 mg/d and the patients receiving aripripazole were started on 15 mg/d to a maximum of 30 mg/d or a minimum of 10 mg/d. Primary outcome targeted cocaine-free urine sample proportions, whereas secondary outcome focused on cocaine craving scores. BSCS was used to assess cocaine craving and the positive and negative symptom scale and the clinical global impression scale were used to monitor psychotic symptom severities. Results and conclusion: In the first study, positive urine tests dropped significantly after 2 weeks, mean cocaine and acohol craving scores declined significantly, and declining psychosis scores were associated with declining cocaine and alcohol craving. In the second study, the proportion of negative drug test results did not differ significantly between patients treated with aripiprazol or perphenazine. Regarding the anticraving effect, in the aripiprazol group during week 3 to 8, significant reductions in craving intensity, frequency and duration were seen, while no similar reduction was seen with perphenazine. In conclusion, although the results are still limited, studies suggest that aripiprazol may have a potential effect in dual diagnosis patients with schizophrenia and CD, possibly due to its dopamine activity as a partial agonist/antagonist.

Review question / Objective: This meta-analysis investigated the value of rsDECT -based non-invasive assessment of the severity of esophagus varices and the risk of hemorrhage in patients with cirrhotic portal hypertension. Eligibility criteria: Studies meeting the following criteria were included: Studies evaluating the effect of rsDECT on EV in patients with hepatic cirrhosis, and published in Chinese or English; The diagnosis was based on acknowledged gold standard. Containing complete four-grid table data of diagnostic tests, which can be extracted directly or indirectly. Review, case-report, conference summary, animal study, and repeatedly published study were excluded.Based on the severity of EV shown in the endoscopy, patients in the study group were classified into the mild EV (EV1), medium EV (EV2), or severe EV (EV3) groups according to the General Rules for Recording Endoscopic Findings of Esophagogastric varices (The Japan Society for Portal Hypertension) : EV1, slightly linear expansions; EV2, moderately beaded expansions; EV3, significantly nodular or neoplastic expansions.