A retrospective study of general hospital patients who commit suicide shortly after being discharged from the hospital

OBJECTIVE

To assess the scope of diagnostic screening for suicide prevention in general hospital patients.

METHODS

Retrospective medical record review of general hospital patients who committed suicide and matched-control subjects who did not commit suicide shortly after being discharged from the hospital.

RESULTS

The suicide rate was 32 per 100 000 patient-years. Eight (73%) of 11 patients who committed suicide were diagnosed with depression, substance use disorder, or both at their last hospital admission compared with 11 (33%) of the controls (P<.05). Only 1 of 44 patients (both cases and controls) was referred for psychiatric consultation.

CONCLUSIONS

The suicide rate in general hospital patients was almost 3-fold higher than in the general population. Depression and/or substance use disorders were risk factors for suicide. Screening for those disorders may be beneficial for suicide prevention in the general hospital population, but will likely benefit more patients who will not commit suicide.

Maternal life history--versus gestation-focused assessment of prenatal exposure to substances of abuse

PURPOSE

Substance use by pregnant women is socially stigmatized and may be legally punishable. This societal condemnation raises concerns about underascertainment of prenatal substance exposure of offspring if mothers are asked specifically about their behavior during gestation, versus their life histories without reference to gestational dates. This study assessed agreement between life history-focused and pregnancy-focused assessments of prenatal exposure, and percentages of offspring classified as exposed to a range of substances by each measure, in a sample of school-aged children of methadone-maintained, opioid-dependent parents.

METHODS

Prenatal exposure was assessed in 172 offspring of 109 mothers by: (a) questionnaires administered to mothers about substance use during pregnancy; and (b) best-estimate (BE) diagnoses of substance use disorders in mothers overlapping with pregnancy dates. BE diagnoses were based on interviews with the Schedule for Affective Disorders and Schizophrenia-Lifetime Version, conducted by trained mental health professionals with mothers about their life histories of psychiatric and substance use disorders, as well as mothers' medical records. Chance-corrected agreement between the measures was examined using kappa statistics. Percentages of offspring classified as exposed by each method were compared using McNemar chi 2 tests.

RESULTS

Except for cigarettes, agreement between the measures was poor. Except for alcohol, diagnosed episodes of substance use disorders in mothers with dates overlapping pregnancy classified more offspring as exposed than mothers' responses to the questionnaire focusing on behavior while pregnant, though the differences in proportions identified as exposed were not always large or statistically significant.

IMPLICATIONS

When retrospective ascertainment of prenatal exposure is necessary, asking mothers for their own life histories, without reference to pregnancy dates, may be the preferred approach.

Antisocial personality and depression among incarcerated drug treatment participants

PURPOSE

The co-occurrence of antisocial personality (ASP) and depression among drug-dependent individuals was examined in a sample of federal inmates participating in residential or outpatient drug and alcohol treatment to increase our understanding of the co-occurrence of these disorders.

METHODS

We examined drug dependence patterns both by the number of drugs of dependence as well as by type of drug, and separately studied men and women. The Diagnostic Interview Schedule (DIS) was used to obtain DSM-III-R diagnostic information on a sample of 609 men and women participating in a multi-site drug treatment evaluation project. Logistic regression results are reported that compared lifetime rates of ASP and major depression by number of drugs of dependency for men and women. ASP and major depression diagnostic rates were also examined by type of drug dependency pattern among men.

RESULTS

We found that both the number of drugs as well as the type of drug(s) are related to prevalence patterns for both diagnoses. The high rates of ASP and major depression among specific subgroups of drug-dependent inmates highlight the need for thorough psychiatric assessment and the tailoring of treatment programs to the issues associated with these diagnoses.

IMPLICATIONS

Our results suggest that although there are similarities in co-morbidity between men and women, the differences point to the need to study men and women separately.

Hospital-based adolescent substance abuse treatment: comorbidity, outcomes, and gender

Positive change was demonstrated on a number of self-report scales administered to 129 adolescents at a hospital-based substance abuse program, of whom 72 were posttested after 8 weeks. Female subjects showed change on more measures than male subjects, and a greater number of female subjects went from the clinical to subclinical range. Based on number of sessions attended, subjects were grouped by "dose" into either "hi-attenders" or "lo-attenders." A Trials (pretest/posttest) x Dose interaction revealed significant reduction in drug use at posttest for hi-attenders who were initially heavier users. Multiple regression analyses determined how well "comorbidity" predicted attendance and change in drug use. Although comorbidity failed to predict attendance consistently, male subjects who reported more internalizing symptomatology reduced their drug use to a greater extent than those low on this dimension, and female subjects who initially reported experiencing more family problems became more self-efficacious about future drug avoidance.

Investigating the neurocognitive deficits associated with chronic drug misuse

Cognitive deficits associated with the chronic abuse of drugs have important theoretical and clinical significance: such deficits reflect changes to the underlying cortical, sub-cortical and neuromodulatory mechanisms that underpin cognition, and also interfere directly with rehabilitative programs. Recent investigations have been made into the neuropsychology of chronic abuse of cannabis, stimulants and opiates. It is suggested that future progress in this area, involving developing advances in brain-imaging and neuropharmacology, will capitalize on experimental demonstrations of specific patterns of impairments in decision-making, attention and memory function.

A review of temporal effects and outcome predictors in substance abuse treatment studies with long-term follow-ups. Preliminary results and methodological issues

This article is an initial report from a review of alcohol and drug treatment studies with follow-ups of 2 years or more. The goals of the review are to examine the stability of substance use outcomes and the factors that moderate or mediate these outcomes. Results from 12 studies that generated multiple research reports are presented, and methodological problems encountered in the review are discussed. Substance use outcomes at the group level were generally stable, although moderate within-subject variation in substance use status over time was observed. Of factors assessed at baseline, psychiatric severity was a significant predictor of outcome in the highest percentage of reports, although the nature of the relationship varied. Stronger motivation and coping at baseline also consistently predicted better drinking outcomes. Better progress while in treatment, and the performance of pro-recovery behaviors and low problem severity in associated areas following treatment, consistently predicted better substance use outcomes.

Organizational adoption of preemployment drug testing

This study explored the adoption of preemployment drug testing by 360 organizations. Survival models were developed that included internal organizational and labor market factors hypothesized to affect the likelihood of adoption of drug testing. Also considered was another set of variables that included social and political variables based on institutional theory. An event history analysis using Cox regressions indicated that both internal organizational and environmental variables predicted adoption of drug testing. Results indicate that the higher the proportion of drug testers in the worksite's industry, the more likely it would be to adopt drug testing. Also, the extent to which an organization uses an internal labor market, voluntary turnover rate, and the extent to which management perceives drugs to be a problem were related to likelihood of adoption of drug testing.

Suggested specifications for a standardized Addiction Severity Index database

The Addiction Severity Index (ASI) has become one of the most widely used instruments in the addictions field. As a result of its wide popularity, there are multiple versions of the instrument in use, and a wide range of computer systems used to collect and/or store ASI data. Thus, it has been difficult for different users and systems to share ASI data. This difficulty significantly reduces the value of the information for treatment providers, policy makers, and researchers. This article provides operational definitions and specifications for a "Standard ASI Database." Descriptions for standard variable names, data types, field lengths, value labels, range checks, and programming notes for all items in the fifth edition of the ASI are available electronically from the senior. Examples from the full protocol and the rationale for producing the Standard ASI Database elements are illustrated here. It is hoped that the format suggested will become the "industry standard" for ASI data storage among all users of the ASI and that, regardless of the software used or the method of data collection, there will be a single, standard format for all ASI databases. The potential applications from such a database would benefit treatment providers/clinicians and researchers as well as payers and policy makers.

[How to distinguish between illness, injury or intoxication in the emergency unit?]

BACKGROUND

Clinical judgement of intoxicated patients is difficult. In the emergency department of the inner city of Oslo this is done every day.

MATERIAL AND METHODS

During a one-year period from 1998-99, a group of 429 first-time admitted intoxicated patients were included in a study. The patients and the method of observation are described.

RESULTS

75% of the patients were men; 45% reported to have consumed alcohol only, while 10% had taken a heroin overdose. The rest had used various combinations of legal and illegal drugs. Female patients were younger than male patients (29 versus 36 years, p < 0.00), and patients intoxicated only on alcohol were on the average older than patients who had taken drugs (38 versus 31 years, p < 0.00). 57 patients were hospitalized, seven of them had serious intracerebral conditions.

INTERPRETATION

Our study indicates that systematic observation over some hours, repeated clinical examinations, and the systematic use of a modified Glasgow Coma Scale makes it possible to sort out the seriously ill from "only" intoxicated patients.

Ethnicity, substance use, and development: exemplars for exploring group differences and similarities

Epidemiological research shows some ethnic-group differences in the prevalence of substance use. This approach does not address the question of whether there are ethnic-group differences in the models that are needed to understand the development of substance use. For this question we need to understand the relations between psychological constructs and their trajectories over time. In this paper we describe some approaches to studying ethnic-group differences in the predictors of substance use that illustrate probing for mediators, multisample analyses of structural models, and an experimental trial of a preventive intervention. Our studies found some ethnic-group differences in the structure of constructs and the relations between variables, but many similarities. The challenge for researchers is using appropriate research methods for studying ethnicity, uncovering the basis for ethnic-group differences when they occur, knowing when statistical differences are meaningful, and acknowledging when developmental models are comparable.

Nalbuphine hydrochloride dependence in anabolic steroid users

Nalbuphine hydrochloride, a nonscheduled opioid agonist/antagonist analgesic, is currently approved for the treatment of pain. Recently, nalbuphine dependence was reported in three anabolic steroid users in Britain. To further document this phenomenon, we conducted interviews on eleven subjects who reported nalbuphine use. Eight subjects were clinically dependent on nalbuphine, and seven of the subjects who were asked about tolerance and withdrawal with nalbuphine acknowledged these symptoms. Eight subjects, who had never used drugs intravenously before, reported using nalbuphine by this route. Nalbuphine-related morbidity was extensive and included medical complications and psychiatric symptoms. Nalbuphine users also exhibited a high rate of comorbid Axis I disorders, including other substance misuse. Virtually all subjects described widespread nalbuphine use in the gymnasiums they frequented. These observations, together with the recent increase in nalbuphine-related articles in the lay press, suggest that nalbuphine may represent a new drug of abuse among athletes, especially those using anabolic steroids, and that nalbuphine's scheduling status may need to be re-evaluated.

Substance abuse and criminal recidivism: a prospective study of adolescents

Studies of substance abuse among delinquents have shown mixed results on criminal recidivism. The present study evaluates personality traits associated with substance abuse and recidivism among delinquent boys, and prospectively determines the extent to which these factors are predictive of criminal recidivism. 134 incarcerated boys (x = 15.9 +/- 1.1) completed the Weinberger Adjustment Inventory and the Substance Abuse Screening Inventory. Youth were prospectively followed for up to 4.5 years following release. Among incarcerated delinquents, personality traits are predictive of a positive substance abuse screen and recidivism. A trend indicating a possible interaction between personality and treatment is observed. If these findings are replicated, personality traits may play a role in predicting substance abuse as well as individual delinquent responses to treatment.

Social anxiety disorder: comorbidity and its implications

Social anxiety disorder is an extremely common and potentially disabling psychiatric disorder. Generalized social anxiety disorder, a subtype of the disorder, is believed to be the most common and most severe form. It is also the form that is most often associated with other psychiatric disorders. Unless the clinician has a high index of suspicion, social anxiety disorder may remain undetected. The clinical and treatment implications of the most common psychiatric comorbidities associated with social anxiety disorder are discussed in this article, with a focus on major depression, panic disorder, posttraumatic stress disorder, and alcohol abuse/dependence. Other psychiatric disorders and some medical conditions commonly associated with social anxiety disorder are briefly mentioned. Finally, a differential diagnosis of social anxiety disorder is described. Individuals who present for treatment of other anxiety disorders, mood disorders, or alcohol/substance abuse disorders should be considered at risk for current but undetected social anxiety disorder.

Difficulties in diagnosis and management of bipolar disorder: three case presentations

Bipolar disorder is associated with significant problems in patient management, including misdiagnosis, noncompliance, and comorbid substance use disorders. This article describes strategies for the management of difficult cases, with particular emphasis on the choice of therapeutic agents, such as mood stabilizers and atypical antipsychotics, for optimal control of symptoms and psychosocial interventions for reinforcement of therapeutic interventions. Special attention is given to the relationship between bipolar disorder and substance use disorders.

Utility of collateral information in assessing substance use among psychiatric outpatients

PURPOSE

This study addressed the utility of collateral informants for validating self-reported substance use by psychiatric outpatients.

METHODS

Participants were 92 men and women with severe and persistent Axis I disorders, attending outpatient programs at a public psychiatric facility. As part of a substance use assessment, each participant identified a collateral who would provide information about the participant's substance use in the last month. The collaterals consisted of family (35%), peers (23%), and others (40%) who were primarily mental health staff.

RESULTS

Comparisons of participant and collateral reports showed high percent agreement with significant but modest measures of association. The likelihood that collateral reports will have information value (i.e., corroborate or exceed self-reports) was greater when the topic is illicit drug use and the frequency of contact is once a week or more. In this sample, siblings were more likely to be uninformative than other types of collaterals, whereas treatment staff were comparable to other types of collaterals in the information value of their corroborative reports. Overall, the collateral reports rarely provided more information than was provided by the participants themselves.

IMPLICATIONS

This pattern is consistent with the pattern observed in non-psychiatric samples and supports the accuracy of self-reported substance use by psychiatric outpatients.

Bipolar disorder: diagnostic challenges and treatment considerations

A review of the criteria for the diagnosis of bipolar disorder identifies a number of complicating factors that historically have interfered with the accurate and precise diagnosis of patients. Patients with different subtypes of the disorder sometimes present with different symptoms, and the careful diagnostician must be aware of them. These include comorbidity of bipolar disorder and attention-deficit/hyperactivity disorder, comorbidity of bipolar disorder and substance abuse, and mania secondary to prescription drugs or physical illness, particularly in the elderly. As a result of these factors and others. bipolar disorder is significantly underdiagnosed. Accurate and precise diagnosis has a direct impact on the choice of treatment and will be easier for those clinicians who are aware of the several subtypes of mania and depression and are familiar with the relevant Expert Consensus Guidelines for treatment.

Gender differences in risk factors for trauma exposure and post-traumatic stress disorder among inner-city drug abusers in and out of treatment

Over the past two decades there has been a growing awareness of the comorbidity between post-traumatic stress disorder (PTSD) and substance use disorders in the general population. The purpose of these analyses was to examine, in a population of drug users, the role of gender in (1) predicting the nature of the traumatic event and PTSD symptoms, (2) patterns of substance use disorders in relation to trauma exposure and PTSD symptoms, (3) comorbidity of other psychiatric disorders with trauma exposure and PTSD, and (4) the temporal association of substance use disorder, exposure to trauma, and PTSD. Drug abusers (n = 464) were interviewed using the Diagnostic Interview Schedule for DSM-III-R (DIS) and the Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM). Although more women than men met criteria for DSM-III-R PTSD, there were no gender differences on endorsement for a traumatic event. Adult antisocial behavior, affective disorder, schizophrenia, other anxiety disorder and polysubstance use predicted exposure to an event, whereas, only schizophrenia and other anxiety disorder predicted PTSD. In men, drug use preceded the exposure to an event, while in women, the onset age for both drug use and exposure to an event were nearly identical. This work suggests implications for gender-based education and prevention interventions.

A two-item conjoint screen for alcohol and other drug problems

BACKGROUND

Although nonmedical use of illicit and prescription drugs is not uncommon among American adults, the currently recommended screens for substance use disorders focus only on alcohol. This study reports on the criterion validity of a two-item conjoint screen (TICS) for alcohol and other drug abuse or dependence for a split sample of primary care patients.

METHODS

Two random samples of primary care patients aged 18 to 59 years responded to several screening items that emanated from a focus group process. The DSM-III-R criteria for substance use disorders, as codified by the Composite International Diagnostic Interview-Substance Abuse Module, served as the criterion standard.

RESULTS

At least one positive response to the TICS (In the last year, have you ever drunk or used drugs more than you meant to? and Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?) detected current substance use disorders with nearly 80% sensitivity and specificity. The TICS was particularly sensitive to polysubstance use disorders. Respondents who gave 0, 1, and 2 positive responses had a 7.3%, 36.5%, and 72.4% chance of a current substance use disorder, respectively; likelihood ratios were 0.27, 1.93, and 8.77. The results were consistent across split samples of 434 and 702 participants.

CONCLUSIONS

Current alcohol or other drug problems can be detected in nearly 80% of young and middle-aged patients by asking two questions that are easily integrated into a clinical interview.