Axis I and II disorders as long-term predictors of mental distress: a six-year prospective follow-up of substance-dependent patients

Destination Matters More: Relapse following Hospital-Based Treatment of Substance Use Disorders With and Without Co-Occurring Disorders

OBJECTIVES

Addressing substance use in psychiatric care encounters significant barriers, but the emergence of specialized services offers an opportunity to advance and scale up the integration of addiction services within psychiatric settings. However, research gaps still exist in this field, particularly in understanding the substance relapse rates of people with co-occurring disorders after a psychiatric hospitalization. This study aimed to investigate and compare the relapse rates of patients under inpatient care with exclusively addiction-related issues and those with co-occurring disorders after a hospitalization in a psychiatric ward and gain insights into differences in outcomes for these two patient groups.

METHODS

This retrospective analysis examined electronic medical records of patients admitted to the Acute Psychiatry Ward of the Hospital Clinic of Barcelona with a substance use disorder diagnosis between January 2019 and February 2021. Cox regression was used to identify variables independently associated with the first relapse episode.

RESULTS

From a total of 318 admissions (79.2% with psychiatric comorbidity), 76.1% relapsed during the study follow-up, with a median survival time of 54 days. Younger age, female gender, voluntary admission, and outpatient follow-up were independently associated with relapse. The presence of a co-occurring disorder was not associated with relapse.

CONCLUSION

This study highlights the need for interventions aimed at improving post-discharge abstinence rates for addiction-related hospitalizations. It also challenges the notion that co-occurring disorders automatically imply a worsened prognosis and emphasizes the importance of addressing addiction and psychiatric comorbidity in a comprehensive, integrated, and specialized manner.

Effect of integrated hepatitis C virus treatment on psychological distress in people with substance use disorders

People with substance use disorders (SUD) have a high prevalence of chronic hepatitis C virus (HCV) infection and mental health disorders. We aimed to assess the impact of integrated HCV treatment on psychological distress measured by Hopkins-symptom-checklist-10 (SCL-10). This multi-center randomized controlled trial evaluated psychological distress as a secondary outcome of integrated HCV treatment (INTRO-HCV trial). From 2017 to 2019, 289 participants were randomly assigned to receive either integrated or standard HCV treatment with direct-acting antiviral therapy. Integrated HCV treatment was delivered in eight decentralized outpatient opioid agonist therapy clinics and two community care centers; standard treatment was delivered in internal medicine outpatient clinics at centralized hospitals. Participants in the integrated treatment arm had a sustained virologic response of 93% compared to 73% for those in standard treatment arm. Psychological distress was assessed using SCL-10 prior to initiation of HCV treatment and 12 weeks after treatment completion. The mean SCL-10 score prior to HCV treatment was 2.2 (standard deviation [SD]: 0.7) for patients receiving integrated HCV treatment and 2.2 (SD: 0.8) for those receiving standard HCV treatment. Twelve weeks after the end of treatment, the mean SCL-10 score change was - 0.1 (- 0.3;0.0) in the integrated compared to the standard arm. Psychological distress did not substantially change during the treatment period and was not significantly different between the treatment arms.

Food addiction and dietary restraint in postpartum women: The role of childhood trauma exposure and postpartum depression

The early postpartum period is a sensitive time for understanding women's high-risk eating (i.e., eating behavior associated with negative health outcomes) given potential long-term eating behavior implications for infants. Food addiction and dietary restraint are two high-risk eating phenotypes associated with long-term negative health outcomes that have been theoretically linked. Yet, no research has considered how much these constructs overlap during the early postpartum period. The present study sought to characterize these two high-risk eating phenotypes in postpartum women to examine whether these are distinct constructs with specific etiologies and to inform future targets of intervention. Women (N = 277) in the early postpartum period reported on high-risk eating, childhood trauma exposure, depression symptoms, and pre-pregnancy weight. Women's height was measured and pre-pregnancy BMI was calculated. We conducted bivariate correlations and path analysis to characterize the relationship between food addiction and dietary restraint, controlling for pre-pregnancy BMI. Results showed that food addiction and dietary restraint were not significantly associated and that women's childhood trauma exposure and postpartum depression were associated with food addiction but not dietary restraint. Sequential mediation revealed that higher levels of childhood trauma exposure were associated with worse postpartum depression and, in turn, greater food addiction during the early postpartum period. Findings suggest that food addiction and dietary restraint have distinct psychosocial predictors and etiological pathways, which suggests important construct validity differences between the two high-risk eating phenotypes. Interventions seeking to address food addiction in postpartum women and mitigate the impact of this high-risk eating phenotype on the next generation may benefit from treating postpartum depression, especially in women with histories of childhood trauma exposure.

Inpatients in substance use treatment with co-occurring psychiatric disorders: a prospective cohort study of characteristics and relapse predictors

BACKGROUND

The characteristics of substance use disorder (SUD) inpatients with co-occurring psychiatric disorders (COD) have been scantly described in the extant literature. This study investigated psychological, demographic and substance use characteristics in these patients, along with predictors of relapse 3 months post-treatment.

METHODS

Prospective data from a cohort of 611 inpatients were analyzed for demographics, motivation, mental distress, SUD diagnosis, psychiatric diagnoses (ICD-10) and relapse rate at 3 months post-treatment (retention rate = 70%).

RESULTS

Compared to patients without COD (n = 322), those with COD (n = 289) were younger, had higher mental distress, lower education and higher likelihood of no permanent residence. The relapse rate was also higher in patients with COD (39.8%) relative to patients without COD (26.4%) (OR = 1.85, 95% CI: 1.23-2.78). The relapse rate was particularly high for patients with COD who were diagnosed with cannabis use disorder (53.3%). Multivariate analysis revealed that among patients with COD, relapse was more likely for individuals with a cannabis use disorder (OR = 2.31, 95% CI: 1.34-4.00), and less likely for older ages (OR = 0.97, 95% CI: 0.94-1.00), females (OR = 0.56, 95% CI: 0.33-0.98) and for those with higher intrinsic motivation (OR = 0.58, 95% CI: 0.42-0.81).

CONCLUSION

This study showed that among SUD inpatients, those with COD had relatively persistent high levels of mental distress and an increased risk of relapse. Enhanced measures aimed at COD patients' mental health problems during the inpatient stay, along with close and personalized follow-up after discharge from residential SUD treatment may reduce the probability of relapse in this group.

The burden of somatic diseases among people with alcohol- and drug use disorders are influenced by mental illness and low socioeconomic status. A registry-based cohort study in Norway

OBJECTIVES

Persons with alcohol use disorder (AUD) and drug use disorder (DUD) have a lower life expectancy than the general population. We examined the burden of somatic diseases among persons with AUD or DUD and investigated impact of socioeconomic status (SES) and mental health disorders on the co-occurrence of somatic diseases in these groups.

METHODS

We performed a retrospective, register-based cohort study with a 6-year follow-up of persons (aged ≥18 y) with AUD (13,478) or DUD (16,659). Cox regression analyses were used to estimate hazard ratios (HRs) of somatic diseases.

RESULTS

Patients with DUD were, on average, 10 years younger at the point of diagnosis than patients with AUD. Mental illnesses were prominent in both groups (AUD: 40.5%, and DUD: 46.9% vs 3.5% in controls). Adjusting for mental disorders, the risk of all somatic diseases among the AUD and DUD groups was reduced by 30%. Some of the elevated risk of somatic diseases among persons with AUD and DUD is explained by low SES, though less than that explained by the presence of mental disorders. The diseases with highest risk among AUD patients were metabolic disorders (16.9-fold) and hypertension (14.8-fold), and among AUD patients, viral hepatitis (23.3-fold), after adjusting for low SES and mental disorders.

CONCLUSIONS

Persons with AUD had a higher risk of most somatic diseases, while those with DUD had specific risks for infections and viral hepatitis. Mental health disorders and SES adjusted the associations regarding most somatic diseases. In general, improvement of socio-economic conditions, preferably in combination with professional support to self-manage mental health problems, will reduce the risk of somatic illness in both groups. For DUD patients, available sterile user equipment will reduce the risk of viral hepatis.

Former inpatients’ narratives of substance use four years after substance use disorder treatment: A qualitative follow-up study

Aim: The aim of this study was to explore the narratives of former substance use disorder (SUD) inpatients about substance use after their discharge from long-term SUD treatment in 2017. Method: We conducted semi-structured in-depth interviews with 11 former inpatients of SUD treatment. The data were analysed using a qualitative, thematic analysis model. Findings: During the analysis, two main themes emerged pertaining to participant reflections on substance use – their experience of non-problematic substance use (that is, substance use without declining into pre-treatment levels of misuse behaviours) and problematic substance use (that is, substance use associated with destructive patterns). All participants except one had engaged in substance use after their discharge three to four years ago. The commonly used substance was alcohol, which also appeared to be the most common substance for which there was consensus among the informants regarding non-problematic use. Conclusions: Most of the participants continued to use substances in some way, and some reported that such use did not affect them negatively. Healthcare providers and therapists in SUD treatment should avoid defining a relapse or failed treatment outcome in concrete terms. What is perceived as an actual relapse or a failed treatment outcome is highly subjective. Furthermore, complete sobriety might not necessarily be the best or the only way to measure the SUD treatment stay. An improvement in the quality of life and well-being, even when core symptoms are still present, may be considered a successful treatment outcome.

A Narrative Literature Review of the Epidemiology, Etiology, and Treatment of Co-Occurring Panic Disorder and Opioid Use Disorder

OBJECTIVE

Panic disorder is a debilitating psychiatric disorder that often co-occurs with substance use disorders. Given the current opioid epidemic, the high reported rates of comorbid panic disorder and opioid use disorder are particularly concerning. In this narrative review, we describe the literature on panic disorder and opioid use disorder co-occurrence.

METHODS

86 studies, 26 reviews, 2 commentaries, and 5 guidelines pertaining to opioid use disorder, panic disorder, and their comorbidity were identified using all EBSCO databases, PubMed, and Google Scholar.

RESULTS

First, we review epidemiological literature on the prevalence of the comorbid condition above and beyond each disorder on its own. Additionally, we discuss the challenges that complicate the differential diagnosis of panic disorder and opioid use disorder and contribute to difficulties establishing rates of comorbidity. Second, we review three theoretical models that have been proposed to explain high rates of co-occurring panic disorder and opioid use disorder: the precipitation hypothesis, the self-medication hypothesis, and the shared vulnerability hypothesis. Third, we outline how co-occurring panic and opioid use disorder may impact treatment for each condition.

CONCLUSION

Based on findings in the field, we provide recommendations for future research as well as treatment considerations for co-occurring panic and opioid use disorders.

Substance use and symptoms of mental health disorders: a prospective cohort of patients with severe substance use disorders in Norway

BACKGROUND

There is high co-occurrence of substance use disorders (SUD) and mental health disorders. We aimed to assess impact of substance use patterns and sociodemographic factors on mental health distress using the ten-item Hopkins Symptom Checklist (SCL-10) over time.

METHODS

Nested prospective cohort study of 707 participants with severe SUD across nine opioid-agonist-therapy outpatient clinics and low-threshold municipality clinics in Norway, during 2017-2020. Descriptive statistics were derived at baseline and reported by means and standard deviation (SD). A linear mixed model analysis was used to assess the impact of substance use patterns and sociodemographic factors on SCL-10 sum score with beta coefficients with 95% confidence intervals (CI).

RESULTS

Mean (SD) SCL-10 score was 2.2 (0.8) at baseline with large variations across patients. We observed more symptoms of mental health disorders among people with frequent use of benzodiazepines (beta 3.6, CI:2.4;4.8), cannabis (1.3, CI:0.2;2.5), opioids (2.7, CI:1.1;4.2), and less symptoms among people using frequent stimulant use (- 2.7, CI:-4.1;-1.4) compared to no or less frequent use. Females (1.8, CI:0.7;3.0) and participants with debt worries (2.2, CI:1.1;3.3) and unstable living conditions (1.7, CI:0.0;3.3) had also higher burden of mental health symptoms. There were large individual variations in SCL-10 score from baseline to follow-up, but no consistent time trends indicating change over time for the whole group. 65% of the cohort had a mean score > 1.85, the standard reference score.

CONCLUSIONS

People with SUD have a considerable burden of mental health symptoms. We found no association between substance use patterns and change in mental health symptoms over time. This could suggest that the differences observed were indicating flattening of effects or self-medication to a larger degree than medication-related decline in mental health. This call for better individualized mental health assessment and patient care.

Long-term changes in delay discounting following a smoking cessation treatment for patients with depression

BACKGROUND

Delay discounting (DD) has been identified as a trans-disorder process underlying addictive behaviors, including smoking. Previous studies have evaluated how different treatments for drug dependence have affected DD, showing mixed results. Furthermore, no study has examined the effects of changes in depression on DD rates. The aim of this study was to evaluate the impact of treatment type: cognitive behavioral treatment (CBT), CBT + behavioral activation (BA), or CBT + BA + contingency management (CM), and changes in smoking status and depression on DD rates in long-term follow-up among a sample of treatment-seeking smokers with depression.

METHODS

Participants were 180 treatment-seeking smokers with depression who were randomly assigned to one of the following treatment conditions: CBT (n = 60), CBT + BA (n = 60), and CBT + BA + CM (n = 60). Depressive symptomatology and major depression diagnosis were evaluated through the BDI-II and the SCID-I of the DSM-IV-TR. DD rates were assessed using the DD task with hypothetical monetary rewards. Smoking status, DD, and depressive symptomatology were collected at baseline, at end-of-treatment and at one-, two-, three-, and six-month follow-ups.

RESULTS

CM for smoking cessation reduces DD rates (p = .0094). Smoking abstinence (p = .0024) and reduction in depressive symptoms (p = .0437) were associated with decreases in DD rates in long-term follow-up.

CONCLUSIONS

CM interventions for smoking cessation, smoking abstinence, and the improvement of depression contribute to reductions in DD over time.

The prevalence of mental disorders and patterns of comorbidity within a large sample of mentally ill prisoners: A network analysis

BACKGROUND

Comorbidity has profound implications in both the clinical field and research, yet little is known about the prevalence and structure of comorbid mental disorders. This article aims not only to present data on the prevalence of mental disorders and comorbidity, but also to explore relationships between comorbid mental disorders by using a network approach.

METHODS

Data used in this cross-sectional study are part of a prospective cohort study within penitentiary psychiatric centers (PPCs) in the Netherlands. It includes DSM diagnoses of 5,257 unique male patients incarcerated in one of the PPC's. Prevalence rates of mental disorders and comorbidity were calculated, the network of comorbid DSM diagnoses was constructed using regression coefficients.

RESULTS

Schizophrenia spectrum and substance-related disorders were most prevalent within this sample (56.7 and 43.1%, respectively), and over half of all patients were diagnosed with a comorbid disorder (56.9%). Four distinctive groups of disorders emerged from the network analysis of DSM diagnoses: substance use, impulsivity, poor social skills, and disruptive behaviors. Psychotic disorders were considered as a separate group as it was unconnected to other disorders.

CONCLUSIONS

Comorbid mental disorders can be described, at least in part, as connected networks. Underlying attributes as well as direct influences of mental disorders on one another seem to be affecting the presence of comorbidity. Results could contribute to the understanding of a possible causal relation between psychopathology and criminal behavior and the development of treatment programs targeting groups of disorders.

Depression and Outcomes of Methadone and Buprenorphine Treatment Among People with Opioid Use Disorders: A Literature Review

Objective: Depression is the most common psychiatric comorbidity among people with opioid use disorders (OUDs). However, whether and how comorbid depression is associated with the outcomes of opioid agonist therapy (OAT) remains poorly understood. The objective of this review was to identify and describe the association between depression and main outcomes (opioid use and treatment retention) of methadone and buprenorphine treatment among people with OUDs. Methods: A literature review was conducted by searching five electronic databases (MEDLINE, PubMed, Embase, Evidence-Based Medicine Reviews [EBMR], and Cumulative Index of Nursing and Allied Health Literature [CINAHL] Complete) from January 1970 to April 2019. Two independent reviewers screened titles and abstracts of the identified records by using pre-established eligibility criteria. Next, full texts were reviewed and studies that met inclusion criteria were selected. Finally, a descriptive synthesis of extracted data was performed. Results: In total, 12,296 records were identified and 18 studies that met inclusion criteria were retained. Of these, six studies reported reduced opioid use and seven reported increased opioid use during methadone or buprenorphine treatment. In addition, three studies reported an increased retention rate and four documented a decreased retention rate during methadone or buprenorphine treatment. The remaining studies did not find any significant association between depression and opioid use or treatment retention. Overall, the evidence did not demonstrate a consistent association between depression and outcomes of methadone or buprenorphine treatment. Conclusions: Although the inconsistent nature of the current evidence prohibited us from drawing definitive conclusions, we posit that the presence of depression among OUDs patients may not always predict negative outcomes related to retention and drug use during the course of OAT. Particularly, the hypothesis that adequate treatment of depression can improve treatment retention is promising and is in line with the call for increased efforts to provide integrated care for comorbid mental health disorders and addiction. Future studies with rigorous methodology are essential to better characterize the complex interplay between depression, OAT, and OUDs.

Perceived Self-Control is Related to Mental Distress in Patients Entering Substance Use Disorder Treatment

BACKGROUND

Levels of mental distress are high in patients with substance use disorders (SUD) and investigation of correlates may broaden our understanding of this comorbidity.

OBJECTIVES

We investigated self-reported symptoms of mental distress among individuals entering either outpatient opioid maintenance treatment (OMT) or other inpatient SUD treatment and related factors, with a particular focus on perceived self-control.

METHODS

A cross-sectional study including substance users (n = 548; mean age 34 years; 27% women) entering treatment at 21 different treatment-centers across Norway, interviewed between December 2012 and April 2015. Symptoms of mental distress were assessed with Global Symptom Index (GSI) score. Adjusted relative risk ratios (RRR) with 95% confidence intervals (CI) were estimated through multinomial logistic regression.

RESULTS

More than half of the participants in both treatment groups reported mental distress (GSI) above clinical cut-off. The use of alcohol and exposure to violence were associated with increased likelihood of high GSI for both patient groups. Also, lower perceived self-control was related to high GSI in both treatment groups.

CONCLUSION

Symptoms of mental distress were equally common among patients entering OMT and those entering other inpatient SUD treatment, even if the patients differed on a number of clinical characteristics. Use of alcohol and exposure to violence were associated with more mental distress in both groups. Perceived self-control also appeared to be important when explaining symptoms of mental distress among these SUD patients.

Predictors of Dropout From Inpatient Substance Use Treatment: A Prospective Cohort Study

Introduction:

Dropout from inpatient treatment for substance use disorder (SUD) is an ongoing challenge. The aim of this study was to identify demographic, substance use, and psychological factors that predict dropout from postdetoxification inpatient SUD treatment.

Materials and methods:

A total of 454 patients from 5 inpatient SUD centers in Central Norway were consecutively included in this naturalistic, prospective cohort study.

Results:

A total of 132 patients (28%) did not complete the planned treatment stay (dropped out). Cox regression analysis showed that higher levels of intrinsic motivation for changing personal substance use reduced the dropout risk (adjusted hazard ratio [adjHR]: 0.62, 95% confidence interval [CI]: 0.48-0.79). Higher levels of mental distress were associated with an increased risk for dropout (adjHR: 1.48, 95% CI: 1.11-1.97).

Conclusions:

The role of mental health and motivation in reducing dropout risk from inpatient SUD treatment should be targeted in future prospective intervention studies.

Circulating cytokine levels are associated with symptoms of depression and anxiety among people with alcohol and drug use disorders

BACKGROUND

Psychological distress is common among people with a substance abuse disorder in treatment. Identifying correlates of psychological distress may serve as points of intervention to improve substance abuse treatment outcomes. Immune function measured as cytokine levels have been associated with psychological distress, but this association remains unexplored among people with a substance abuse disorder in treatment. This study aimed to examine whether cytokine levels in patients treated for a substance use disorder were related to depression, anxiety, and overall psychological distress, and to observe these associations separately among people with a past year alcohol use disorder and those with a past year drug use disorder.

METHODS

We collected cross-sectional data from 80 inpatients at five alcohol and substance abuse treatment centers in Norway. We determined alcohol and drug diagnoses, and assessed symptoms of depression, anxiety, and overall psychological distress. We tested blood samples for IL-1, IL-6, TNF-α, INF-γ, and IL-10. We used multivariate linear regressions to examine the associations between cytokine levels and psychological distress measures.

RESULTS

All cytokines were significantly and positively associated with depression score. INF-γ was significantly and negatively associated with anxiety, and IL-6 was significantly and positively associated psychological distress. Among people with only an alcohol use disorder, IL-6 was positively associated with depression and psychological distress scores, and IL-10 was negatively associated with anxiety score. Among people with only a drug use disorder, TNF-α was positively associated with depression score.

CONCLUSION

The relationship between immune function and psychological distress is robust in the context of substance abuse, and further research is warranted.

Kappa opioid receptor antagonism and chronic antidepressant treatment have beneficial activities on social interactions and grooming deficits during heroin abstinence

Addiction is a chronic brain disorder that progressively invades all aspects of personal life. Accordingly, addiction to opiates severely impairs interpersonal relationships, and the resulting social isolation strongly contributes to the severity and chronicity of the disease. Uncovering new therapeutic strategies that address this aspect of addiction is therefore of great clinical relevance. We recently established a mouse model of heroin addiction in which, following chronic heroin exposure, 'abstinent' mice progressively develop a strong and long-lasting social avoidance phenotype. Here, we explored and compared the efficacy of two pharmacological interventions in this mouse model. Because clinical studies indicate some efficacy of antidepressants on emotional dysfunction associated with addiction, we first used a chronic 4-week treatment with the serotonergic antidepressant fluoxetine, as a reference. In addition, considering prodepressant effects recently associated with kappa opioid receptor signaling, we also investigated the kappa opioid receptor antagonist norbinaltorphimine (norBNI). Finally, we assessed whether fluoxetine and norBNI could reverse abstinence-induced social avoidance after it has established. Altogether, our results show that two interspaced norBNI administrations are sufficient both to prevent and to reverse social impairment in heroin abstinent animals. Therefore, kappa opioid receptor antagonism may represent a useful approach to alleviate social dysfunction in addicted individuals.

Mental distress following inpatient substance use treatment, modified by substance use; comparing voluntary and compulsory admissions

Background

Treatment services to patients with substance use disorders (SUDs), including those mandated to treatment, needs to be evaluated and evidence based. The Norwegian Municipal Health Care Act (NMHCA) calls for compulsory treatment for persons with “severe and life-threatening substance use disorder” if these individuals are not otherwise willing to be voluntarily treated and consequently risk their lives over drug use. Mental distress is known to be high among SUD patients admitted to inpatient treatment. The purpose of this study is to describe changes in mental distress from admission to a 6-month follow-up in patients with SUDs, which underwent either voluntary or compulsory treatment.

Method

This prospective study followed 202 hospitalized patients with SUDs who were admitted voluntarily (VA; n = 137) or compulsorily (CA; n = 65). Levels of mental distress were assessed with SCL-90-R. Of 123 patients followed-up at 6 months, 97 (62 VA and 35 CA) had rated their mental distress at admission, discharge and follow-up. Sociodemographics and substance use severity were recorded with the use of The European Addiction Severity Index (EuropASI). We performed a regression analysis to examine factors associated with changes in psychiatric distress at the 6-month follow-up.

Results

The VA group exhibited higher mental distress than the CA group at admission, but both groups improved significantly during treatment. At the 6-month follow-up, the VA group continued to show reduced distress, but the CA group showed increases in mental distress to the levels observed before treatment. The deterioration appeared to be associated with higher scores that reflected paranoid ideas, somatization, obsessive-compulsive symptoms, interpersonal sensitivity, and depression. Active substance use during follow-up was significantly associated with increased mental distress.

Conclusion

In-patient treatment reduces mental distress for both CA and VA patients. The time after discharge seems critical especially for CA patients regarding active substance use and severe mental distress. A greater focus on continuing care initiatives to assist the CA patients after discharge is needed to maintain the reduction in mental distress during treatment. Continuing-care initiatives after discharge should be intensified to assist patients in maintaining the reduced mental distress achieved with treatment.

Trial registration

ClinicalTrials.gov NCT 00970372 December 02, 2016.

The Depression, Anxiety and Stress Scale (DASS-21) as a Screener for Depression in Substance Use Disorder Inpatients: A Pilot Study

Depression is a common co-morbid disorder in substance use disorder (SUD) patients. Hence, valid instruments are needed to screen for depression in this subpopulation. In this study, the predictive validity of the Depression, Anxiety and Stress Scale (DASS-21) for the presence of a depressive disorder was investigated in SUD inpatients. Furthermore, differences between DASS-21 scores at intake and those recorded one week after inpatient detoxification were assessed in order to determine the measurement point of the assessment of the DASS-21 leading to the best predictive validity. The DASS-21 was administered to 47 patients at intake and shortly after inpatient detoxification. The results of the DASS-21 were compared to the Mini International Neuropsychiatric Interview (MINI), which served as the gold standard. Levels of sensitivity and specificity of 78-89% and 71-76% were found for the DASS-21 assessed after detoxification, satisfactorily predicting depression as diagnosed with the MINI. Total DASS-21 scores as well as the DASS subscale for depression were significantly reduced at the second measurement, compared to the DASS at intake. We conclude that the DASS-21 may be a suitable instrument to screen for depressive disorders in SUD patients when administered (shortly) after detoxification. Future research is needed to support this conclusion.

Challenges in detecting and diagnosing substance use in women in the acute psychiatric department: a naturalistic cohort study

BACKGROUND

This study examines sex differences in substance use and substance use disorder in the acute psychiatric department, and possible interactions between sex and clinical and social factors associated with this phenomenon.

METHODS

Data concerning substance use were collected in a naturalistic cohort study (n = 384, 51.6% male, 48.4% female) in an acute psychiatric department. Recent intake of substances at admission, diagnosis of substance use disorder and demographic and socioeconomic information were recorded. At admission, serum and urine samples were analysed for substance use and breath analysis was performed for alcohol levels.

RESULTS

Twice as many men as women were diagnosed with substance use disorder, whereas there were no gender differences in the number of positive toxicology screenings. Toxicology screening revealed the use of non-prescribed medication with addiction potential in 40% of both female and male patients many of whom did not report this in the admission interview. A low level of education in men and absence of parental responsibility in women showed a statistically significant interaction with a current diagnosis of substance use disorder.

CONCLUSIONS

Despite no sex differences in positive toxicology screenings in the acute psychiatric department, twice as many men as women are diagnosed with substance use disorders. The use of prescription drugs with addiction potential was widely under-reported by both sexes, in patients with no prescriptions for the medications. Women with no parental responsibility are overrepresented among those diagnosed with substance use disorder, as are men with a low level of education.

TRIAL REGISTRATION

The study is registered with the ClinicalTrials.gov identifier NCT01415323.

Associations between personality disorder characteristics and treatment outcomes in people with co-occurring alcohol misuse and depression

BACKGROUND

Personality disorders are highly comorbid with alcohol misuse and depressive symptomatology; however, few studies have investigated treatment outcomes in this population. The aim of this study was to examine relationships between baseline personality disorder cluster profiles and overall and treatment-related changes for those with co-occurring alcohol misuse and depression.

METHODS

Secondary analysis was conducted using a subset of data (N = 290) from two randomised controlled trials of psychological interventions for co-occurring alcohol misuse and depression, which did not specifically target personality disorders. Baseline dimensional personality disorder cluster scores were derived from the International Personality Disorder Examination Questionnaire (IPDEQ). Four treatment conditions were compared: a brief integrated intervention, followed by no further treatment, or nine further sessions of integrated-, alcohol-, or depression-focused treatment. Associations between IPDEQ scores and changes in alcohol use, depressive symptoms and functioning from baseline to the 6- and the 12-month follow-ups were of primary interest.

RESULTS

Personality disorder cluster scores moderately negatively impacted on overall change (primarily Cluster C), as well as treatment-related outcomes (primarily Cluster A), particularly changes in depressive symptoms and psychosocial functioning. Longer interventions appeared to be more effective in the longer-term (e.g., at 12-month follow-up), with integrated interventions relatively more effective than single-focused ones for individuals with higher personality disorder cluster scores.

CONCLUSIONS

Greater attention needs to be paid to particular personality disorder clusters during the assessment and treatment of individuals with co-occurring alcohol misuse and depression. Integrated interventions, incorporating motivational interviewing and cognitive behaviour therapy, may provide a useful therapeutic framework. Integrated interventions also provide opportunities for adjunctive components focussing on other issues and coping strategies (e.g., to offset negative affective states), potentially tailored to the characteristics and needs of individual participants.

Co-occurrence between mental distress and poly-drug use: a ten year prospective study of patients from substance abuse treatment

INTRODUCTION

Longitudinal research investigating psychiatric trajectories among patients with poly-drug use patterns remains relatively scant, even though this specific population is at elevated risk for multiple negative outcomes. The present study examined temporal associations between poly-drug use (i.e. heroin, cannabis, tranquilizers, and amphetamines) and mental distress over a 10-year period.

METHODS

A clinical cohort of 481 patients was recruited from substance use treatment facilities in Norway, and prospectively interviewed 1, 2, 7 and 10years after the initial data collection at treatment admission. At each assessment participants completed a questionnaire addressing their substance use and mental distress. Longitudinal growth models were used to examine whether, and if so, how, levels of drug use were associated with the level and rate of change in mental distress over time.

RESULTS

Results from the longitudinal growth models showed a co-occurrence between active poly-drug use and mental distress, such that there was a dose-response effect where mental distress increased both in magnitude and over time with the number of drugs used. Reduction in mental distress during the 10-year study period was evident only in the no-drug use condition. Use of multiple drugs and mental distress appear strongly co-related over time.

CONCLUSIONS

Pre-treatment assessment should carefully identify individuals manifesting poly-drug use and mental disorders. Treatment and follow-up services should be tailored to their specific needs.

Quality of life improved following in-patient substance use disorder treatment

BACKGROUND

Quality of life (QoL) is increasingly recognized as central to the broad construct of recovery in patients with substance use disorders (SUD). However, few longitudinal studies have evaluated changes in QoL after SUD treatment and included patients with SUD that were compulsorily hospitalized. This study aimed to describe QoL among in-patients admitted either voluntarily or compulsorily to hospitalization and to examine patterns and predictors of QoL at admission and at 6 months post treatment.

METHODS

This prospective study followed 202 hospitalized patients with SUD that were admitted voluntarily (N=137) or compulsorily (N=65). A generic QoL questionnaire (QoL-5) was used to assess QoL domains. Regression analysis was conducted to identify associations with QoL at baseline and to examine predictors of change in QoL at a 6-month follow-up.

RESULTS

The majority of patients had seriously impaired QoL. Low QoL at baseline was associated with a high psychiatric symptom burden. Fifty-eight percent of patients experienced a positive QoL change at follow-up. Although the improvement in QoL was significant, it was considered modest (a mean 0.06 improvement in QoL-5 scores at follow-up; 95% confidence interval: 0.03 - 0.09; p<0.001). Patients admitted voluntarily and compulsorily showed QoL improvements of similar magnitude. Female gender was associated with a large, clinically relevant improvement in QoL at follow-up.

CONCLUSIONS

In-patient SUD treatment improved QoL at six month follow-up. These findings showed that QoL measurements were useful for providing evidence of therapeutic benefit in the SUD field.

The impact of alcohol use severity on anxiety treatment outcomes in a large effectiveness trial in primary care

OBJECTIVE

The presence of anxiety disorders is associated with poorer alcohol use disorder treatment outcomes, but little is known about the impact of alcohol use problems on anxiety disorder treatment outcomes despite their high comorbidity. The current study examined the impact of alcohol use symptom severity on anxiety disorder treatment outcomes in a multi-site primary care effectiveness study of anxiety disorder treatment.

METHOD

Data came from the Coordinated Anxiety Learning and Management (CALM) effectiveness trial. Participants (N=1004) were randomized to an evidence-based anxiety intervention (including cognitive behavioral therapy and medications) or usual care in primary care. Participants completed measures of alcohol use, anxiety, and depression at baseline, 6-, 12-, and 18-month follow-up periods. Patients with alcohol dependence were excluded.

RESULTS

There were no significant moderating (Treatment Group × Alcohol Use Severity) interactions. The majority of analyses revealed no predictive effects of alcohol use severity on outcome; however, alcohol problems at baseline were associated with somewhat higher anxiety and depression symptoms at the 18-month follow-up.

CONCLUSIONS

These data indicate that patients with alcohol problems in primary care can be effectively treated for anxiety disorders. Baseline alcohol problems were associated with some poorer long-term outcomes, but this was evident across CALM and usual care. These findings provide preliminary evidence that there may be no need to postpone treatment of anxiety disorders until alcohol problems are addressed, at least among those who have mild to moderate alcohol problems. Replication with more severe alcohol use disorders is needed.

Distinct mu, delta, and kappa opioid receptor mechanisms underlie low sociability and depressive-like behaviors during heroin abstinence

Addiction is a chronic disorder involving recurring intoxication, withdrawal, and craving episodes. Escaping this vicious cycle requires maintenance of abstinence for extended periods of time and is a true challenge for addicted individuals. The emergence of depressive symptoms, including social withdrawal, is considered a main cause for relapse, but underlying mechanisms are poorly understood. Here we establish a mouse model of protracted abstinence to heroin, a major abused opiate, where both emotional and working memory deficits unfold. We show that delta and kappa opioid receptor (DOR and KOR, respectively) knockout mice develop either stronger or reduced emotional disruption during heroin abstinence, establishing DOR and KOR activities as protective and vulnerability factors, respectively, that regulate the severity of abstinence. Further, we found that chronic treatment with the antidepressant drug fluoxetine prevents emergence of low sociability, with no impact on the working memory deficit, implicating serotonergic mechanisms predominantly in emotional aspects of abstinence symptoms. Finally, targeting the main serotonergic brain structure, we show that gene knockout of mu opioid receptors (MORs) in the dorsal raphe nucleus (DRN) before heroin exposure abolishes the development of social withdrawal. This is the first result demonstrating that intermittent chronic MOR activation at the level of DRN represents an essential mechanism contributing to low sociability during protracted heroin abstinence. Altogether, our findings reveal crucial and distinct roles for all three opioid receptors in the development of emotional alterations that follow a history of heroin exposure and open the way towards understanding opioid system-mediated serotonin homeostasis in heroin abuse.

Psychometric characteristics of the Drug Use Disorders Identification Test (DUDIT) and the Drug Use Disorders Identification Test-Extended (DUDIT-E) among young drug users in Hungary

BACKGROUND

The Drug Use Disorders Identification Test (DUDIT) was developed for problematic substance use screening, and for a more detailed assessment of problematic use, the Drug Use Disorders Identification Test-Extended (DUDIT-E) was additionally developed.

PURPOSE

Examining the psychometric properties of DUDIT and DUIT-E across diverse settings in populations of young drug users.

METHODS

We examined the psychometric characteristics of these instruments across various settings in populations of young substance users differing in substance use severity and treatment status. Data were collected from three clinically relevant groups (n = 259) as well as a control sample of college students (n = 109).

RESULTS

Reliability analyses indicated good internal consistency for both instruments; high intraclass correlations further indicated good test-retest reliability. Differences among study groups were significant on the DUDIT scale and all DUDIT-E subscales (p < 0.01), with the target groups exhibiting higher scores compared to controls. A two-factor solution was identified for the factor structure of DUDIT.

CONCLUSION

The Hungarian version of DUDIT and DUDIT-E can effectively identify substance use problems among young users.

Psychometric properties of the Turkish versions of the Drug Use Disorders Identification Test (DUDIT) and the Drug Abuse Screening Test (DAST-10) in the prison setting

The aim of this study was to evaluate psychometric properties of the Drug Use Disorders Identification Test (DUDIT) and the Drug Abuse Screening Test (DAST-10) in prisoners with (n = 124) or without (n = 78) drug use disorder. Participants were evaluated with the DUDIT, the DAST-10, and the Addiction Profile Index-Short (API-S). The DUDIT and the DAST-10 were found to be psychometrically sound drug abuse screening measures with high convergent validity when compared with each other (r = 0.86), and API-S (r = 0.88 and r = 0.84, respectively), and to have a Cronbach's α of 0.93 and 0.87, respectively. In addition, a single component accounted for 58.28% of total variance for DUDIT, whereas this was 47.10% for DAST-10. The DUDIT had sensitivity and specificity scores of 0.95 and 0.79, respectively, when using the optimal cut-off score of 10, whereas these scores were 0.88 and 0.74 for the DAST-10 when using the optimal cut-off score of 4. Additionally, both the DUDIT and the DAST-10 showed good discriminant validity as they differentiated prisoners with drug use disorder from those without. Findings support the Turkish versions of both the DUDIT and the DAST-10 as reliable and valid drug abuse screening instruments that measure unidimensional constructs.

The kappa opioid receptor: from addiction to depression, and back

Comorbidity is a major issue in psychiatry that notably associates with more severe symptoms, longer illness duration, and higher service utilization. Therefore, identifying key clusters of comorbidity and exploring the underlying pathophysiological mechanisms represent important steps toward improving mental health care. In the present review, we focus on the frequent association between addiction and depression. In particular, we summarize the large body of evidence from preclinical models indicating that the kappa opioid receptor (KOR), a member of the opioid neuromodulatory system, represents a central player in the regulation of both reward and mood processes. Current data suggest that the KOR modulates overlapping neuronal networks linking brainstem monoaminergic nuclei with forebrain limbic structures. Rewarding properties of both drugs of abuse and natural stimuli, as well as the neurobiological effects of stressful experiences, strongly interact at the level of KOR signaling. In addiction models, activity of the KOR is potentiated by stressors and critically controls drug-seeking and relapse. In depression paradigms, KOR signaling is responsive to a variety of stressors, and mediates despair-like responses. Altogether, the KOR represents a prototypical substrate of comorbidity, whereby life experiences converge upon common brain mechanisms to trigger behavioral dysregulation and increased risk for distinct but interacting psychopathologies.

Substance use disorders and anxiety: a treatment challenge for social workers

Converging evidence from epidemiologic and treatment studies indicate that anxiety disorders and substance use disorders commonly co-occur, and the interaction is multifaceted and variable. Epidemiological studies and investigations within clinical substance abuse populations have found an association between anxiety disorders and substance use disorders. Specific anxiety disorders including generalized anxiety disorder, panic disorder, and post traumatic stress disorder have all been associated with substance use. The association with obsessive-compulsive disorder is less robust, and some research has found a negative association. The risk of nicotine dependence is significantly higher among individuals with an anxiety disorder, and conversely, smoking has been found to be associated with trait anxiety and anxiety disorders. A review of the current literature and the relationship between specific anxiety disorders and alcohol and substance use disorders is discussed in detail. This article, written for social workers in a variety of practice settings, reviews the prevalence, diagnostic, and treatment issues at the interface of substance use disorders and anxiety disorders.

Anxiety and alcohol use disorders: comorbidity and treatment considerations

The co-occurrence of anxiety disorders and alcohol use disorders (AUDs) is relatively common and is associated with a complex clinical presentation. Sound diagnosis and treatment planning requires that clinicians have an integrated understanding of the developmental pathways and course of this comorbidity. Moreover, standard interventions for anxiety disorders or AUDs may need to be modified and combined in targeted ways to accommodate the unique needs of people who have both disorders. Optimal combination of evidence-based treatments should be based on a comparative balance that considers the advantages and disadvantages of sequential, parallel, and integrated approaches.

Treatment of comorbid substance use and anxiety disorders: a case study

This case study of combined anxiety with both alcohol and benzodiazepine dependence illustrates key issues in presentation, differential diagnosis and management. The case is discussed from a biopsychosocial perspective with each of the discussants focusing on their particular area of experience and expertise, then the treatment package is presented in an integrated fashion. Of particular interest is how social anxiety disorder may become a significant barrier to engagement and retention, and thus outcome in persons presenting for addiction treatment, and how a treatment plan for such patients can be built.

A cross-sectional study of patients with and without substance use disorders in Community Mental Health Centres

BACKGROUND

Epidemiological studies have consistently established high comorbidity between psychiatric disorders and substance use disorders (SUD). This comorbidity is even more prominent when psychiatric populations are studied. Previous studies have focused on inpatient populations dominated by psychotic disorders, whereas this paper presents findings on patients in Community Mental Health Centres (CMHCs) where affective and anxiety disorders are most prominent. The purpose of this study is to compare patients in CMHCs with and without SUD in regard to differences in socio-demographic characteristics, level of morbidity, prevalence of different diagnostic categories, health services provided and the level of improvement in psychiatric symptoms.

METHODS

As part of the evaluation of the National Plan for Mental Health, all patients seen in eight CMHCs during a 4-week period in 2007 were studied (n = 2154). The CMHCs were located in rural and urban areas of Norway. The patients were diagnosed according to the ICD-10 diagnoses and assessed with the Health of the Nation Outcome Scales, the Alcohol Use Scale and the Drug Use Scale.

RESULTS

Patients with SUD in CMHCs are more frequently male, single and living alone, have more severe morbidity, less anxiety and mood disorders, less outpatient treatment and less improvement in regard to recovery from psychological symptoms compared to patients with no SUD.

CONCLUSION

CMHCs need to implement systematic screening and diagnostic procedures in order to detect the special needs of these patients and improve their treatment.

Poor mental health and sexual risk behaviours in Uganda: a cross-sectional population-based study

BACKGROUND

Poor mental health predicts sexual risk behaviours in high-income countries, but little is known about this association in low-income settings in sub-Saharan Africa where HIV is prevalent. This study investigated whether depression, psychological distress and alcohol use are associated with sexual risk behaviours in young Ugandan adults.

METHOD

Household sampling was performed in two Ugandan districts, with 646 men and women aged 18-30 years recruited. Hopkins Symptoms Checklist-25 was used to assess the presence of depression and psychological distress. Alcohol use was assessed using a question about self-reported heavy-episodic drinking. Information on sexual risk behaviour was obtained concerning number of lifetime sexual partners, ongoing concurrent sexual relationships and condom use.

RESULTS

Depression was associated with a greater number of lifetime partners and with having concurrent partners among women. Psychological distress was associated with a greater number of lifetime partners in both men and women and was marginally associated (p = 0.05) with having concurrent partners among women. Psychological distress was associated with inconsistent condom use among men. Alcohol use was associated with a greater number of lifetime partners and with having concurrent partners in both men and women, with particularly strong associations for both outcome measures found among women.

CONCLUSION

Poor mental health is associated with sexual risk behaviours in a low-income sub-Saharan African setting. HIV preventive interventions should consider including mental health and alcohol use reduction components into their intervention packages, in settings where depression, psychological distress and alcohol use are common.

Reduction in mental distress among substance users receiving inpatient treatment

BACKGROUND

Substance users being admitted to inpatient treatment experience a high level of mental distress. In this study we explored changes in mental distress during treatment.

METHODS

Mental distress, as measured by the HSCL-10, was registered at admission and at discharge among 164 substance users in inpatient treatment in Northern Norway. Predictors of reduction in mental distress were examined utilizing hierarchical regression analysis.

RESULTS

We found a significant reduction in mental distress in the sample, but the number of patients scoring above cut-off on the HSCL-10 at discharge was still much higher than in the general population. A more severe use of substances as measured by the AUDIT and the DUDIT, and being female, predicted a higher level of mental distress at admission to treatment as well as greater reduction in mental distress during treatment. Holding no education beyond 10 year compulsory school only predicted a reduction in mental distress.

CONCLUSIONS

The toxic and withdrawal effects of substances, level of education as well as gender, contributed to the differences in change in mental distress during treatment. Regression to the mean may in part explain some of the findings.

Longitudinal relationship between psychological distress and multiple substance use: results from a three-year multisite natural-history study of rural stimulant users

OBJECTIVE

Substance use is associated with poor mental health, but little is known regarding how use of multiple substances is associated with mental health, particularly longitudinally, in community studies. This article examines this issue in a large (N = 710), natural-history study of rural stimulant (cocaine and/or methamphetamine) users in three states.

METHOD

Respondent-driven sampling recruited recent (past-30-day) stimulant users in three counties each in Arkansas, Kentucky, and Ohio. Participants were interviewed every 6 months for 3 years. Mental health was measured by the Brief Symptom Inventory, and prior 6 months' substance use was measured for 17 possible substances. Data analysis used generalized estimating equations for longitudinal data with the Global Severity Index of the Brief Symptom Inventory as the dependent variable at each interview and substance use as predictor variables measured by number of substances used in the past 6 months and, separately, the 17 individual substances, adjusting for use of substance-use treatment, demographics, and recruitment site.

RESULTS

On average, both Global Severity Index score and use of many substances declined over the course of study. Global Severity Index score was significantly associated with (a) greater number of substances used in the past 6 months (p < .0001) and (b) use of crack cocaine, methamphetamine, and nonprescription use of prescription painkillers and tranquilizers.

CONCLUSIONS

Multiple and specific substances appear to incrementally increase psychological distress. Users of cocaine and methamphetamine are present in rural areas; these associations with poor psychological health raise concerns regarding availability of local treatment services for individuals with mental-health problems, as well as substance abuse.

Personality factors associated with methadone maintenance dose

OBJECTIVES

Methadone is the most frequently prescribed medication for the treatment of opioid dependence in the U.S., and questions relating to appropriate dosing of methadone remain an important issue. Given accumulating evidence suggesting an elevated prevalence of personality pathology in opioid dependent populations, as well as evidence of an association between Cluster B characteristics and substance use severity, we hypothesized that patients with such pathology would have elevated methadone dose prescriptions.

METHODS

Participants were 54 opioid dependent individuals recruited from a methadone maintenance clinic.

RESULTS

RESULTS indicated that participants with symptoms consistent with Cluster B pathology had a significantly higher mean prescribed methadone dose relative to participants without Cluster B pathology.

CONCLUSION

The presence of personality traits appears to influence methadone maintenance. Implications of this finding are discussed.

Estimating co-occurring behavioral trajectories within a neighborhood context: a case study of multivariate transition models for clustered data

Comorbidity is well-documented in psychiatric and risk behavior epidemiology. The authors present a novel application of clustered multivariate transition models to study comorbidity within a clustered context. The authors used data from the Project on Human Development in Chicago Neighborhoods (1995-2002) to assess trajectories in substance use, problems with police, and antisocial behavior among 1,517 participants in 80 neighborhoods followed from ages 12-15 years through ages 18-21 years. The authors used pairwise odds ratios to quantify behavior comorbidity at the individual and neighborhood levels. Risk behaviors co-occurred within individuals at specific points in time: antisocial behavior and substance use were 3.37 times more likely to co-occur within an individual at wave 1, as compared with the co-occurrence of any 2 behaviors from different individuals, while substance use and police problems were 2.94 times more likely to co-occur than substance use and antisocial behavior at wave 2. The authors also evaluated sequential comorbidity. Antisocial behavior was sequentially comorbid with substance use and police problems: 31% of youths who had reported antisocial behavior at baseline reported police problems or drug use at wave 2. These models can prove instrumental in answering the persistent questions about possible sequential relations among problem behaviors.

Protocol: Personality assessment as a support for referral and case-work in treatment for substance use disorders (PASRC-study)

BACKGROUND

Assessment of co-morbid personality disorders in substance use disorders may lead to important insights concerning individual patients. However, little is known about the potential value of routine personality disorder assessment in a clinical context.

METHODS

Patients are adults with past-year substance dependence seeking treatment at a centralized intake unit for substance abusers in the City of Copenhagen. A randomized controlled trial of assessment of personality disorders and individual feedback vs. a general life situation interview. Patients are followed at 3 and 6 months post-treatment

DISCUSSION

If routine personality assessment improves outcomes of substance abuse treatment, the clinical implication is to increase the use of personality disorder assessment in substance abuse treatment settings.

TRIAL REGISTRATION

Current controlled trials ISRCTN39851689.

Five-Factor Model personality profiles of drug users

BACKGROUND

Personality traits are considered risk factors for drug use, and, in turn, the psychoactive substances impact individuals' traits. Furthermore, there is increasing interest in developing treatment approaches that match an individual's personality profile. To advance our knowledge of the role of individual differences in drug use, the present study compares the personality profile of tobacco, marijuana, cocaine, and heroin users and non-users using the wide spectrum Five-Factor Model (FFM) of personality in a diverse community sample.

METHOD

Participants (N = 1,102; mean age = 57) were part of the Epidemiologic Catchment Area (ECA) program in Baltimore, MD, USA. The sample was drawn from a community with a wide range of socio-economic conditions. Personality traits were assessed with the Revised NEO Personality Inventory (NEO-PI-R), and psychoactive substance use was assessed with systematic interview.

RESULTS

Compared to never smokers, current cigarette smokers score lower on Conscientiousness and higher on Neuroticism. Similar, but more extreme, is the profile of cocaine/heroin users, which score very high on Neuroticism, especially Vulnerability, and very low on Conscientiousness, particularly Competence, Achievement-Striving, and Deliberation. By contrast, marijuana users score high on Openness to Experience, average on Neuroticism, but low on Agreeableness and Conscientiousness.

CONCLUSION

In addition to confirming high levels of negative affect and impulsive traits, this study highlights the links between drug use and low Conscientiousness. These links provide insight into the etiology of drug use and have implications for public health interventions.

Predictors of suicide attempters in substance-dependent patients: a six-year prospective follow-up

Background

This is a six-year prospective follow-up of a former cross sectional study of suicide attempters in a sample of treatment-seeking substance-dependent patients. The aims were to explore the frequency of patients with new suicide attempts (SA) during the six-year observation period, and to explore the predictive value of lifetime Axis I and II disorders, measured at index admission, on SA in the observation period, when age, gender and substance-use variables, measured both at admission and at follow-up, were controlled for.

Methods

A consecutive sample of 156 alcohol-dependent and 131 poly-substance-dependent inpatients and outpatients in two Norwegian counties were assessed at index admission (T1) with the Composite International Diagnostic Interview (Axis I disorders), Mon's Clinical Multiaxial Inventory (Axis II disorders) and Hopkins Symptom Checklist-25 (mental distress). At follow-up six years later (T2), 56% (160/287 subjects, 29% women) were assessed using the HSCL-25 and measures of harmful substance use (Alcohol Use Disorders Identification Test and Drug Use Disorders Identification Test).

Results

The prevalence of patients with SA between T1 and T2 was 19% (30/160), with no difference between sexes or between patient type (alcohol-dependent versus poly-substance-dependent). Sober patients also attempted suicide. At the index admission, lifetime eating disorders, agoraphobia with and without panic disorder, and major depression were significantly and independently associated with SA. Prospectively, only lifetime dysthymia increased the risk of SA during the following six years, whereas lifetime generalized anxiety disorder reduced the risk of SA. Individually, neither the numbers of Axis I and Axis II disorders nor the sum of these disorders were independently related to SA in the observation period. Substance use measured at T1 did not predict SA in the follow-up period, nor did harmful use of substances at follow-up or in the preceding year.

Conclusion

A high prevalence of SA was found six years later, both in patients still abusing substances and in sober patients. To prevent SA, treatment of both affective disorders and substance abuse is important.