Patients with schizophrenia are frequently diagnosed with addictive comorbidities, and data in the literature support a 10 to 70% prevalence of this dual diagnosis. Nonetheless, substance use disorders can be missed during the initial interview with a psychotic patient, if the clinician is focused only on the more obvious manifestations. Therefore, using psychometric scales and structured interviews in patients with schizophrenia is strongly encouraged because the case manager will base his/her therapeutic decisions on quantifiable data about these patients’ symptoms and functional status. Clinical management in dual diagnosis cases must address both conditions simultaneously, as the delay in the initiation of substance withdrawal treatment may hinder the recovery from a psychotic episode. An important issue is represented by the potential pharmacologic interactions between drugs administered for schizophrenia and those targeting substance withdrawal and substance dependence. Other important aspects refer to (1) the therapeutic adherence, which can influence the prognosis of both conditions, (2) the negative impact of residual psychotic symptoms and substance-related disorders over the patient quality of life and daily functioning, (3) the necessity to integrate variables like the patient’s specific needs, lifestyle, and psychological resources in the therapeutic decision. These clinical vignettes are focused on clinical, biological, psychometric, and pharmacological dimensions, supporting the formulation of treatment recommendations based on monitoring both psychiatric and biological profiles.
Treatment resistant schizophrenia (TRS) is a severely disabling disorder, which decreases dramatically the quality of life and overall functionality, while it increases the rate of hospital admissions and overall healthcare costs. The main objective of this research was to evaluate the risk factors for TRS in a group of patients based on a retrospective analysis. The secondary objective was to design an algorithm for initial evaluation in patients with schizophrenia, in order to detect the candidates at risk for developing TRS. Medical charts and consultation records of all patients aged between 18 and 30, diagnosed with TRS, evaluated during 1-year in our department, were selected for analysis. The most significant risk factors for TRS found in univariate model were younger age at schizophrenia onset, male gender, living in rural areas, co-morbid drug dependence, lower therapeutic adherence, and premorbid personality disorder. Marginally significant were higher Positive and Negative Syndrome Scale (PANSS) scores at previous admissions, higher scores on PANSS negative symptoms sub-scale, and lower educational background. In the multivariate model, TRS was still significantly predicted (p<0.05) by younger age at the disease onset, addictive co-morbidity, and lower therapeutic adherence. An algorithm based on these risk factors is suggested, based on (a) structured PANSS evaluation using SCI-PANSS and Informant Questionnaire for PANSS, (b) a scale for the detection of co-morbid drug dependence (i.e. Inventory of Drug Taking Situations, IDTS), (c) an interview for detecting premorbid personality disorders (i.e. Structured Clinical Interview for DSM IV – Axis II Disorders, SCID-II), and (d) Treatment Satisfaction Questionnaire for Medication (TSQM) for therapeutic adherence monitoring. Also, the inclusion of several pharmacogenetic parameters (at least CYP450 2D6 panel for detection of poor/ultrarapid metabolizers) could be useful when establishing an adequate therapeutic management, and may help in decreasing the rate of non- response due to variations in antipsychotics plasma levels.
Erectile dysfunction (ED) has an intricate pathogenesis, with organic and psychosocial factors contributing to the shaping of its clinical manifestations and functional impairment. ED disrupts not only an individual’s sexual life but may also contribute to impairments of self-esteem, social functioning, quality of life, overall well-being, mood, etc. The assessment process and therapeutic interventions should be adequate to the specific profile of each patient, therefore an interdisciplinary approach is usually recommended, in order to find the vulnerability factors, recent triggers, psychiatric and organic comorbidities or causes, and elements that contribute to maintaining the sexual dysfunction, such as lifestyle factors, interpersonal conflicts, or inadequate sexual education. This narrative review explores the evidence-based approaches to structured psychiatric, psychological, and therapeutical assessment in patients with ED, and the most validated psychosocial treatments available. The results support the use of recognized diagnostic criteria within DSM-5TR and ICD-11, together with structured instruments (scales, questionnaires, and inventories), in a multidisciplinary approach. The cognitive model and cognitive-emotional model of ED support the initiation of cognitive-behavioral therapy in these patients. Other interventions, like the PLISSIT model, sexual therapy, couple therapy, and sexual-focused psychoeducation are also supported by evidence. In conclusion, ED requires a combined, psychiatric, psychologic, psychotherapeutic, and organic-oriented assessment, with the purpose of tailoring the treatment to the patient’s particularities.
Delirium is associated with lower quality of life, increased healthcare costs, longer hospitalizations, and worse prognosis when detected in patients who are already confronted with a severe and invalidating disease, like the major neurocognitive disorder (MND). In order to identify the most evidence-based interventions that could be included in case management for patients with both delirium and MND, this narrative review explored three electronic databases (Pubmed, Cochrane, and Web of Science/Clarivate) for primary and secondary sources dedicated to this topic. All papers published in English between the inception of each database and September 2024 were screened for relevant data on pharmacological and non-pharmacological therapies targeting delirium. The results supported the use of a multicomponent approach as the first line of treatment, mitigating the precipitating factors, and only as a second line, the use of pharmacological instruments. There is a lack of validated therapies targeting specifically the delirium superimposed on MND, most of the recommendations being extrapolated from studies with delirium in the general population or in elderly patients with different organic diseases. Further studies are required to investigate the specifics of delirium in patients with MND and potential strategies focused on neurobiological mechanisms instead of just clinical manifestations.
