**3. Results**

**1.4. Challenges and perspectives in research**

174 Recent Advances in Drug Addiction Research and Clinical Applications

mental health and addiction treatment fields [71].

dates the psychiatric diagnosis [79,80].

**2. Methods**

Treatment of DD patients requires a thorough understanding of both mental illness and addiction and the consequent integration of the traditional treatment approaches in both the

In the research field, a complicating issue for DD studies is that they may focus on different populations: the general public, the population of subjects referring to psychiatric services, and the population of people currently treated by addiction services [72]. This diversity affecting the research field may be a concrete, challenging reality from a clinical standpoint. In Italy, this is particularly important because the standard practice for patients with comor‐ bid psychiatric disorders and SUD is a parallel treatment. In our country, mental health and addiction facilities have different institutional cultures, etiological concepts, administrative arrangements, screening, and treatment approaches [73]. The problematic issues of such treatment approach include possible flaws in communication, collaboration, and linkage,

which might significantly hinder or complicate comorbidity service delivery [74,75].

Even if it is clearly a changing and growing problem, the number of studies on DD preva‐ lence in patients admitted to psychiatric wards in general hospitals in Italy is still scant. A recent study [76] has focused on differences in the length of stay in first-hospitalization schizophrenic patients with and without comorbid SUD and found that the first showed poorer symptom improvement and required longer stays than the latter. The flaws of communica‐ tion and linkage between psychiatric and addiction services emerged from the study by Preti et al. [77], who reported that only approximately 30% of patients with SUD discharged from acute psychiatric inpatient facilities were referred to drug addiction services. Other issues that have been investigated in this field include SUD in emergency room settings [78], gender differences in DD patients [65], and attempts to understand whether SUD follows or pre‐

Considering these premises, the aim of our study was to describe the sociodemographic and clinical features of DD patients at their first admission to the Psychiatric Ward of University Hospital "Maggiore della Carità" in Novara, Italy. With more detail, we collected data about all patients admitted for the first time during the 2-year periods 2003–2004 and 2013–2014 to (1) assess the extent of comorbidity with drug abuse in a sample of patients at their first admission to a psychiatric ward in a general hospital in Italy; (2) investigate whether there are differences between inpatients with and without comorbid SUD, focusing on sociodemo‐ graphic, clinical, and other background variables in both periods; (3) investigate the possible differences between patients with comorbid SUD in the two 2-year periods; and (4) identify

We performed a retrospective study reviewing the clinical charts of patients at their first admission to the Psychiatric Ward of University Hospital "Maggiore della Carità" in Novara,

the possible predictors of comorbidity with SUD and their changes over a decade.

Patients first admitted to our psychiatric ward and matching the inclusion criteria described above were 227 in 2003–2004 and 257 in 2013–2014, respectively. The percentage of SMI-SUD patients was 25.1% in 2003–2004 and 32.7% in 2013–2014.

We divided patients in the following age categories: <18, 19–40, 41–60, and ≥61 years. In 2003– 2004, SMI and SMI-SUD patients were 1.8% and 3.5% for <18 years, 42.9% and 56.1% for 19– 40 years, 31.2% and 36.8% for 41–60 years, and 24.1% and 3.5% for ≥61 years, respectively. In

2013–2014, SMI and SMI-SUD patients were 2.9% and 7.1% for <18 years, 31.8% and 54.8% for 19–40 years, 38.7% and 33.3% for 41–60 years, and 26.6% and 4.8% for ≥61 years, respec‐ tively. Differences between SMI-SUD and SMI patients in age distribution were statistically significant in both 2-year periods, and patients in the SMI-SUD group were more frequently in the age category 19–40 years; moreover, in 2013–2014, this difference was found also in the age category <18 years.

**Table 1** reports data about sociodemographic features in the 2003–2004 and 2013–2014 groups, further subdivided according to the presence or absence of comorbid SUD. The main statisti‐ cally significant differences between SMI and SMI-SUD patients included gender, occupa‐ tional status, and educational level. SMI-SUD patients compared to SMI patients were more frequently males (70.2% vs 39.4% in 2003–2004 and 70.2% vs 36.6% in 2013–2014) and unemployed (33.3% vs 15.0% in 2003–2004 and 41.3% vs 22.5% in 2013–2014) in both 2-year periods. Furthermore, in 2013–2014, a higher percentage of students (10.0% vs 6.5%) and lower educational level (junior high school; 63.0% vs 37.3%) were found in SMI-SUD patients compared to SMI.


**Table 1.** Sociodemographic features of patients in 2003–2004 and 2013–2014. A comparison of the subgroups of patients, subdivided according to the presence or absence of comorbid SUD.

**Table 2** describes the living accommodation and family features of patients in 2003–2004 and 2013–2014 and the comparison of the subgroups of patients, subdivided according to the presence or absence of comorbid SUD. The main statistically significant differences between SMI and SMI-SUD patients included living accommodation and marital status in both 2-year periods and having kids in 2013–2014. SMI-SUD patients compared to SMI patients lived more frequently with their family of origin (33.9% vs 19.2% in 2003–2004 and 33.8% vs 21.2% in 2013– 2014) rather than with a family of their own, and they were more frequently single (48.2% vs 41.3% in 2003–2004 and 60.2% vs 33.5% in 2013–2014) or divorced in 2003–2004 (28.6% vs 12%). Moreover, in 2013–2014, SMI-SUD patients more frequently had no kids compared to SMI patients.

2013–2014, SMI and SMI-SUD patients were 2.9% and 7.1% for <18 years, 31.8% and 54.8% for 19–40 years, 38.7% and 33.3% for 41–60 years, and 26.6% and 4.8% for ≥61 years, respec‐ tively. Differences between SMI-SUD and SMI patients in age distribution were statistically significant in both 2-year periods, and patients in the SMI-SUD group were more frequently in the age category 19–40 years; moreover, in 2013–2014, this difference was found also in the

**Table 1** reports data about sociodemographic features in the 2003–2004 and 2013–2014 groups, further subdivided according to the presence or absence of comorbid SUD. The main statisti‐ cally significant differences between SMI and SMI-SUD patients included gender, occupa‐ tional status, and educational level. SMI-SUD patients compared to SMI patients were more frequently males (70.2% vs 39.4% in 2003–2004 and 70.2% vs 36.6% in 2013–2014) and unemployed (33.3% vs 15.0% in 2003–2004 and 41.3% vs 22.5% in 2013–2014) in both 2-year periods. Furthermore, in 2013–2014, a higher percentage of students (10.0% vs 6.5%) and lower educational level (junior high school; 63.0% vs 37.3%) were found in SMI-SUD patients

**2003–2004 (***n* **= 227) 2013–2014 (***n* **= 257)**

**Gender ≤0.05 ≤0.05**

**Nationality** 0.209 0.334

**Educational level** 0.179 **≤0.05**

**Occupational status ≤0.05 ≤0.05**

**Table 1.** Sociodemographic features of patients in 2003–2004 and 2013–2014. A comparison of the subgroups of

Male 39.4 (67) 70.2 (40) 36.6 (63) 70.2 (59) Female 60.6 (103) 29.8 (17) 63.4 (109) 29.8 (25)

Italian 94.1 (160) 98.3 (56) 86.7 (150) 82.1 (69) Foreign 5.9 (10) 1.8 (1) 13.3 (23) 17.9 (15)

Primary school 28.8 (49) 28.1 (16) 16.9 (28) 13.6 (11) Junior high school 38.2 (65) 50.9 (29) 37.3 (62) 63.0 (51) High school 24.7 (42) 19.3 (11) 37.9 (63) 18.5 (15) University degree 8.2 (14) 1.8 (1) 7.8 (13) 4.9 (4)

Employed 38.1 (61) 48.1 (26) 31.4 (53) 33.7 (27) Unemployed 15.0 (24) 33.3 (18) 22.5 (38) 41.3 (33) Student 0.0 (0) 0.0 (0) 6.5 (11) 10.0 (8) Disabled/retired 25.6 (41) 7.4 (4) 29.6 (50) 10.0 (8) Other 21.3 (34) 11.1 (6) 10. 1(17) 5.0 (4)

patients, subdivided according to the presence or absence of comorbid SUD.

**SMI, % (***n***) SMI-SUD, % (***n***) p\* SMI, % (***n***) SMI-SUD, % (***n***) p\***

age category <18 years.

176 Recent Advances in Drug Addiction Research and Clinical Applications

compared to SMI.


**Table 2.** Living accommodation and family features of patients in 2003–2004 and 2013–2014. A comparison of the subgroups of patients subdivided according to the presence or absence of comorbid SUD.

Family problems were reported as significantly more common by SMI-SUD patients in the years 2003–2004 than in SMI patients (21.1% vs 8.2 %, p=0.009), although no statistically significant difference was found between the two groups in the years 2013–2014 (47.9% vs 44.0%, p=0.588). Similarly, patients' parents were divorced in a significantly higher percentage of SMI-SUD patients than in SMI patients in the years 2003–2004 (7.0% vs 1.8%, p=0.047), although no significant difference was found in the two groups for this variable in the years 2013–2014 (84.2% vs 76.9%, p=0.604).


**Table 3.** Clinical features of patients in 2003–2004 and 2013–2014. Comparison of the subgroups of patients subdivided according to the presence or absence of comorbid SUD.

**Table 3** reports the clinical and legal features of patients in 2003–2004 and 2013–2014, and the results of the comparison of the subgroups of patients, subdivided according to the presence or absence of comorbid SUD. The main statistically significant differences between SMI and SMI-SUD patients included diagnosis and acts of harm in both 2-year periods and imprison‐ ment in 2003–2004. In 2003–2004, SMI-SUD patients compared to SMI patients were more frequently diagnosed with a personality disorder (52.6% vs 23.5%). In 2013–2014, the same difference was found, albeit less striking (23.8% vs 19.1%), together with a higher percentage of schizophrenia and psychosis in SMI-SUD patients compared to SMI patients (26.2% vs 22.5%). Acts of harm were more common in SMI-SUD patients than in SMI ones in both periods (12.3% vs 4.7% in 2003–2004 and 26.3% vs 11.8% in 2013–2014), whereas imprison‐ ment was significantly more common in SMI-SUD patients only in 2003–2004 (8.8% vs 1.8%).

The following variables were included in the multivariate analysis: gender, nationality, educational level, occupation, marital status, living accommodation, family problems, acts of harm, imprisonment, age at admission, and diagnosis. The statistically significant results of the multivariate analysis performed to investigate the possible predictors of comorbidity with SUD are described in **Table 4**.

In both 2-year periods, female gender and age >61 years were associated with comorbidity with SUD with an OR <1 (adjusted OR 0.24, 95% CI 0.09–0.64, p=0.004 vs adjusted OR 0.15, 95% CI 0.06–0.39, p<0.001; adjusted OR 0.92, 95% CI 0.01–0.81, p=0.031 vs adjusted OR 0.03, 95% CI 0.01–0.31, p=0.003).

Family problems were reported as significantly more common by SMI-SUD patients in the years 2003–2004 than in SMI patients (21.1% vs 8.2 %, p=0.009), although no statistically significant difference was found between the two groups in the years 2013–2014 (47.9% vs 44.0%, p=0.588). Similarly, patients' parents were divorced in a significantly higher percentage of SMI-SUD patients than in SMI patients in the years 2003–2004 (7.0% vs 1.8%, p=0.047), although no significant difference was found in the two groups for this variable in the years

**2003–2004 (***n* **= 227) 2013–2014 (***n* **= 257)**

**Diagnosis ≤0.05 ≤0.05**

**Self-injury behaviors** 32.9 (56) 26.3 (15) 0.350 35.3 (60) 30.0 (24) 0.408 **Acts of harm** 4.7 (8) 12.3 (7) **≤0.05** 11.8 (20) 26.3 (21) **≤0.05 Imprisonment** 1.8 (3) 8.8 (5) **≤0.05** 2.9 (5) 7.4 (6) 0.104

**Table 3.** Clinical features of patients in 2003–2004 and 2013–2014. Comparison of the subgroups of patients subdivided

**Table 3** reports the clinical and legal features of patients in 2003–2004 and 2013–2014, and the results of the comparison of the subgroups of patients, subdivided according to the presence or absence of comorbid SUD. The main statistically significant differences between SMI and SMI-SUD patients included diagnosis and acts of harm in both 2-year periods and imprison‐ ment in 2003–2004. In 2003–2004, SMI-SUD patients compared to SMI patients were more frequently diagnosed with a personality disorder (52.6% vs 23.5%). In 2013–2014, the same difference was found, albeit less striking (23.8% vs 19.1%), together with a higher percentage of schizophrenia and psychosis in SMI-SUD patients compared to SMI patients (26.2% vs 22.5%). Acts of harm were more common in SMI-SUD patients than in SMI ones in both periods (12.3% vs 4.7% in 2003–2004 and 26.3% vs 11.8% in 2013–2014), whereas imprison‐ ment was significantly more common in SMI-SUD patients only in 2003–2004 (8.8% vs 1.8%).

The following variables were included in the multivariate analysis: gender, nationality, educational level, occupation, marital status, living accommodation, family problems, acts of harm, imprisonment, age at admission, and diagnosis. The statistically significant results of the multivariate analysis performed to investigate the possible predictors of comorbidity with

Affective disorders 24.1 (41) 10.5 (6) 17.9 (31) 4.8 (4) Schizophrenia/psychosis 25.3 (43) 7.0 (4) 22.5 (39) 26.2 (22) Personality disorders 23.5 (40) 52.6 (30) 19.1 (33) 23.8 (20) Anxiety disorders 7.6 (13) 0.0 (0) 30.1 (52) 22.6 (19) Other 19.4 (33) 29.8 (17) 10.4 (18) 22.6 (19)

**SMI, % (***n***) SMI-SUD, % (***n***) p\* SMI, % (***n***) SMI-SUD, % (***n***) p\***

2013–2014 (84.2% vs 76.9%, p=0.604).

178 Recent Advances in Drug Addiction Research and Clinical Applications

according to the presence or absence of comorbid SUD.

SUD are described in **Table 4**.

In 2003–2004, having a university degree was associated with a decreased risk of comorbid SUD (adjusted OR 0.04, 95% CI 0.01–0.64, p=0.023), whereas having a diagnosis of personali‐ ty disorder was associated with an increased risk of SMI-SUD comorbidity (adjusted OR 3.51, 95% CI 1.05–11.77, p=0.042).

In 2013–2014, living in therapeutic rehabilitation center (compared to living alone) was associated with a decreased risk of SMI-SUD comorbidity (adjusted OR 0.02, 95% CI 0.01–0.41, p=0.011).



**Table 4.** Multivariate analysis for the assessment of potential predictors of comorbid SUD in psychiatric patients in 2003–2004 and 2013–2014.

As far as substance used is concerned, the assessment of the SMI-SUD sample in 2003–2004 and 2013–2014 highlighted a decrease of alcohol (78.9% of SMI-SUD patients in 2003–2004 vs 64.6% of SMI-SUD patients in 2013–2014) and heroin consumption (19.2% of SMI-SUD patients in 2003–2004 vs 14.6% of SMI-SUD patients in 2013–2014). Polyabuse did not seem to change after 10 years (42.1% vs 42.6%). On the contrary, we found an increase of the use of medica‐ tion, cannabinoids, cocaine, and other drugs (0.05% vs 17.0%, 33.3% vs 57.3%, 28.0% vs 36.5%, and 0.05% vs 17.0%, respectively).

## **4. Discussion**

The percentage of first admissions for SMI-SUD increased from the first to the second 2-year period considered (2003–2004 vs 2013–2014), being 25.1% and 32.7%, respectively. Accord‐ ing to the existing literature, DD is a growing phenomenon. Studies performed in similar settings report a percentage of DD patients ranging from 24% to 51% [85,86]. In Italy, data from mental health departments and from addiction services describe a prevalence of psychiatric disorders with comorbid SUD ranging from 4% to 42%, respectively [87–91].

#### **4.1. Sociodemographic and family features**

Statistically significant differences were found in both periods between SMI and SMI-SUD patients as far as gender, age at admission, occupational status, marital status, and living accommodation are concerned. With more detail, SMI-SUD patients in both 2-year periods were more likely to be male, younger, unemployed, living with parents (or alone, for the 2013– 2014 period) rather than with a family of their own, and single (or divorced, in 2003–2004). All these results are in line with similar reports from most other studies in this field. Regarding marital status and living accommodation, DD patients seem to experience relational prob‐ lems in their families and have difficulties either creating or maintaining lasting relation‐ ships. Besides, comorbidity of psychiatric disorders and SUD may impact on relationships in and of itself. In a previous study [65], we found that this impact was particularly meaningful in female patients. Some differences between SMI and SMI-SUD patients were not shared between the two 2-year periods. For instance, in the 2-year period 2013–2014, SMI-SUD patients were more likely than SMI ones to have a junior high school degree rather than a high school one or a university degree and to have no kids [92]. On the contrary, family problems and parents' divorce were reported as significantly more common by SMI-SUD patients in the years 2003–2004 than in SMI patients. We may suppose an evolving pattern of substance seeking through the years; it may be that the motivation leading to addiction is shifting in most

cases from relief of psychological and emotional distress to active search for pleasure and entactogenic effects. This hypothesis is consistent with the widespread changes in the choice of the main substance of abuse.

Overall, consistent with the literature [91,93], what emerges from these data is that SMI-SUD patients are more likely to have a poorer sociorelational functioning and achievement, albeit our results do not allow to discriminate which came first, whether comorbidity or a poorer performance, which are likely to be strictly intertwined.

#### **4.2. Clinical features**

**2003–2004 2013–2014**

Other 3.94 (0.99–15.69) 0.052 3.11 (0.56–17.11) 0.192

**Table 4.** Multivariate analysis for the assessment of potential predictors of comorbid SUD in psychiatric patients in

As far as substance used is concerned, the assessment of the SMI-SUD sample in 2003–2004 and 2013–2014 highlighted a decrease of alcohol (78.9% of SMI-SUD patients in 2003–2004 vs 64.6% of SMI-SUD patients in 2013–2014) and heroin consumption (19.2% of SMI-SUD patients in 2003–2004 vs 14.6% of SMI-SUD patients in 2013–2014). Polyabuse did not seem to change after 10 years (42.1% vs 42.6%). On the contrary, we found an increase of the use of medica‐ tion, cannabinoids, cocaine, and other drugs (0.05% vs 17.0%, 33.3% vs 57.3%, 28.0% vs 36.5%,

The percentage of first admissions for SMI-SUD increased from the first to the second 2-year period considered (2003–2004 vs 2013–2014), being 25.1% and 32.7%, respectively. Accord‐ ing to the existing literature, DD is a growing phenomenon. Studies performed in similar settings report a percentage of DD patients ranging from 24% to 51% [85,86]. In Italy, data from mental health departments and from addiction services describe a prevalence of psychiatric

Statistically significant differences were found in both periods between SMI and SMI-SUD patients as far as gender, age at admission, occupational status, marital status, and living accommodation are concerned. With more detail, SMI-SUD patients in both 2-year periods were more likely to be male, younger, unemployed, living with parents (or alone, for the 2013– 2014 period) rather than with a family of their own, and single (or divorced, in 2003–2004). All these results are in line with similar reports from most other studies in this field. Regarding marital status and living accommodation, DD patients seem to experience relational prob‐ lems in their families and have difficulties either creating or maintaining lasting relation‐ ships. Besides, comorbidity of psychiatric disorders and SUD may impact on relationships in and of itself. In a previous study [65], we found that this impact was particularly meaningful in female patients. Some differences between SMI and SMI-SUD patients were not shared between the two 2-year periods. For instance, in the 2-year period 2013–2014, SMI-SUD patients were more likely than SMI ones to have a junior high school degree rather than a high school one or a university degree and to have no kids [92]. On the contrary, family problems and parents' divorce were reported as significantly more common by SMI-SUD patients in the years 2003–2004 than in SMI patients. We may suppose an evolving pattern of substance seeking through the years; it may be that the motivation leading to addiction is shifting in most

disorders with comorbid SUD ranging from 4% to 42%, respectively [87–91].

2003–2004 and 2013–2014.

**4. Discussion**

and 0.05% vs 17.0%, respectively).

180 Recent Advances in Drug Addiction Research and Clinical Applications

**4.1. Sociodemographic and family features**

**OR (95% CI) p OR (95% CI) p**

In both 2-year periods examined, psychiatric diagnosis was significantly different between SMI-SUD and SMI patients. This difference is striking in 2003–2004 patients: SMI-SUD patients are more frequently affected by personality disorders and "other" diagnoses (including disturbance of conduct, mental retardation, eating disorders, acute stress reaction, and adaptation reaction), whereas, in 2013–2014, there is still a difference as far as personality disorders is concerned, albeit less striking, together with differences in "other" diagnoses and schizophrenia, which is more frequent in SMI-SUD than in SMI patients. These results are partially consistent with the existing literature [37,94–97] especially because of the underrepresentation of mood disorders in the SMI-SUD group of patients. On the contrary, this change in diagnosis is interesting, as it may suggest a different pattern of substance use after 10 years. It seems that schizophrenic and psychotic patients are more likely, in recent years, to use substances, but it is not clear whether this change suggests a trend towards more selfmedication seeking on behalf of these patients or rather a greater potential of substances to induce long-lasting psychotic symptoms. It should be considered that the type of substances used have changed a lot over a decade; cannabinoid, ecstasy, and new drugs are studied for their potential of inducing psychosis, and in clinical settings, it is quite common to observe long-lasting, medication-resistant psychotic symptoms in young patients who have taken one of the several new synthetic drugs. Besides, these are difficult or impossible to identify and detect with standard laboratory methods.

As far as acts of harm are concerned, these were significantly more common in SMI-SUD patients than in SMI ones, in both 2-year periods, and overall, the percentage of acts of harm was higher in 2013–2014. Several studies have focused on the relation between substance abuse and aggressive behaviors; the use of substances may result in poor insight, neurocognitive impairments, hallucinations, impulsivity, as well as other emotional or physiological prob‐ lems that may underlie aggressiveness. Moreover, some studies report that SMI-SUD patients are more likely to have a criminal history and legal problems than SMI ones [36]. Violent behaviors and substance abuse may be entangled because of the close relationship between drug distribution and the criminal system; moreover, the constant need of money to get the drug may lead patients to aggressive acts to obtain it [98]. Despite the almost 2-fold increase in the percentage of acts of harm from 2003–2004 to 2013–2014, only in 2003–2004 was the frequency of imprisonment significantly different in SMI-SUD and SMI patients, being higher in the first.

As far as substance used is concerned, our findings are consistent with the literature and with clinical observations, especially regarding the increased use of cannabinoids, cocaine, and "other" drugs on the one hand and the decreased consumption of heroin on the other. Surprisingly, we found polyabuse to be relatively stable even after 10 years.

#### **4.3. Multivariate analysis**

In both 2-year periods, female gender and being ≥61 years old appear to be associated with a decreased risk of SMI-SUD comorbidity. Both results are consistent with the existing litera‐ ture and could be expected according to clinical experience [66,85–87,91].

In the 2-year period 2003–2004, having a university degree was associated with a decreased risk of comorbid SMI-SUD, whereas having a diagnosis of personality disorder was associat‐ ed with an increased risk of comorbid SMI-SUD, but 10 years later we found educational level and diagnosis having no impact on comorbidity. As already described above, this may suggest possible changes in the pattern of SUD as far as problematic family issues are concerned; notwithstanding the fact that, in 2013–2014, educational level and diagnosis no longer represented risk factors, it would have been interesting to assess whether individuals with different cultural levels as assessed by schooling of with different diagnosis share the same pathways towards SUD and similar choices regarding type of substance and use. As far as educational level is concerned, in a recent study, we found that, although having a universi‐ ty degree was associated with a decreased risk of DD for males, it was associated with an increased risk of DD in females [65]. We hypothesized a different pattern of social function‐ ing and performance in male and female SMI-SUD patients [44] and that males and females may access substances via different pathways and choose different types of substances as well [99–102], with a variable impact on their lives.

As far as diagnosis is concerned, the same study mentioned above, which assessed the period 2003–2012, found affective and "other" disorders associated with an increased risk of comorbid SUD, compared to personality disorders, which according to Baigent [94] would be more likely than Axis I disorders to be associated with chronic SUD. On the contrary, reports from the literature show mixed results about this issue, and recent studies suggest that the frequency of comorbid SUD is similar in schizophrenic psychoses and in personality disor‐ ders [37] and that primary mood and/or anxiety disorders are at high risk for comorbid SUD as well [96,97].

Last, in the 2-year period 2013–2014, we found that living in therapeutic rehabilitation centers was associated with a decreased risk (compared to living alone) of comorbidity with SUD. This result is encouraging and may support the effectiveness of such therapeutic settings in protecting patients from exposition and/or relapse into SUD.
