ABSTRACT
This contribution reviews the international literature about dual diagnosis, meaning patients who have simultaneously mental health problems and substance use disorders and discusses epidemiology, clinical characteristics, but primarily etiopathogenesis and different treatment models and interventions. The epidemiological data coming from large-scale studies in the general population in USA, Australia and UK demonstrate the close relationship between mental health problems and substance use disorders. Also, the results from Greek research projects support this close relationship, but their research designs have significant limitations. Multiple and high risks are common in this population, like violent or suicidal behavior, self-harm, physical problems, while they appear less responsive to treatment. Subsequently, different models for etiopathogenesis of dual diagnosis have been suggested: (a) Causal relationship: secondary substance use disorder is subsequent of primary mental illness (self-medication hypothesis, supersenstivity model) or vice versa (alcohol, cannabis, and cocaine use trigger or contribute to development of mental illness). (b) Third factor as the cause of both mental and substance use disorders (genetic factor, neuropathology, traumatic experience, personality characteristics, multiple factors). (c) Comorbidty is due to chance. (d) Each disorder mutually exacerbates the other, regardless the cause. Here, the relationship between alcohol and depression is discussed further as example. The ideas and the research-evidence which support each of these models are presented. Also there is an overview of different treatment models: (a) Consecutive treatment: mental health treatment and substance misuse treatment are provided consecutively. (b) Parallel treatments: the patient attends programs of both mental health and substance use services simultaneously. (c) Integrated treatment: the same clinical team addresses both mental health issues and substance use disorders. The first two models have significant weaknesses due to lack of focus on the interaction of the different disorders or to administrative and managerial barriers. On the other hand, integrated programs appear to overcome these limitations. They use modified interventions provided by the same team in order to address the multiple needs of the patients. Different types of integrated programs are discussed. More pragmatist inter ventions should also be taken into consideration. It is expected that some direction for research and clinical practice to Greece will emerge from this contribution.
ABSTRACT
The aim of the study was to determine the prevalence of hepatitis E virus (HEV) infection among individuals at high risk of transmission of non-A, non-B hepatitis or sexually transmitted diseases (STDs), and to evaluate whether they have an increased risk of exposure to HEV. Serum samples from 125 thalassemia patients, 300 intravenous drug users, 420 hemodialysis patients, 263 individuals with STDs, 47 human immunodeficiency virus (HIV) infected homosexual men, and 316 healthy volunteers were tested for immunoglobulin G (IgG) and M (IgM) antibodies to HEV (anti-HEV) by enzyme immunoassays (EIAs) following a predetermined algorithm (Abbott Labs). Anti-HEV IgG was confirmed in 3/125 (2.4%) thalassemia patients, 5/300 (1.7%) intravenous drug users, 27/420 (6.4%) hemodialysis patients, 4/263 (1.5%) STD patients, 1/47 (2.1%) homosexual men, and 7/316 (2.2%) of the reference group. No patient was found positive for anti-HEV IgM. The higher prevalence which was observed in hemodialysis group was due to the confounding effect of age, as multivariate analysis showed. The anti-HEV prevalence increased significantly with age (p = 10(-4)). No significant association was found between anti-HEV, anti-HCV, and anti-HBc. In conclusion, individuals at high risk of non-A, non-B hepatitis and STDs have no increased risk of exposure to HEV and the higher prevalence of anti-HEV IgG among older subjects may be due to an epidemic form of HEV infection which occurred some decades ago, when the sanitary conditions in our country were poor.
