Psychiatric severity and mortality in substance abusers: a 15-year follow-up of drug users

Schema therapy for patients with borderline personality disorder and comorbid alcohol dependence: A multiple-baseline case series design study

This study tested the effectiveness of schema therapy (ST) for borderline personality disorder (BPD) and comorbid alcohol dependence (AD). Twenty patients participated in a case series study with multiple baselines. The baseline phase consisted of treatment as usual. It was followed by a case conceptualization phase, an experiential techniques phase and a behavioural change phase. Patients showed a significant decrease in BPD and AD symptoms; change was mainly accomplished in the experiential techniques phase, with medium to large effect sizes. Three months after termination of therapy, 68% of the patients had remitted from BPD, and the number of drinking days decreased clearly. This study shows that, although treatment is challenging in this group of patients, meaningful change can be obtained in patients with BPD and AD using ST.

Mortality among people with regular or problematic use of amphetamines: a systematic review and meta-analysis

BACKGROUND AND AIMS

Amphetamines are the second most commonly used class of illicit drugs. We aimed to produce pooled estimates of mortality risks among people with regular or dependent use of amphetamines, with a focus upon all-cause mortality as well as specific causes of death.

DESIGN

Systematic review and meta-analysis of cohorts of people with problematic use or dependence on amphetamines with data on all-cause or cause-specific mortality.

SETTING AND PARTICIPANTS

Of 4240 papers, 30 were eligible, reporting on 25 cohorts that measured all-cause mortality, drug poisoning, suicide, accidental injuries, homicide and cardiovascular mortality. Cohorts (n = 35-74 139) were in North America, several Nordic countries and Asia Pacific.

MEASUREMENT

Titles/abstracts were independently screened by one reviewer and excluded those reviewed by a second reviewer. Full-text screening was by two reviewers with discrepancies resolved via a third reviewer. We extracted data on crude mortality rates (CMR) per 100 person-years (py), standardized mortality ratios (SMRs). We imputed SMRs where possible if not reported by study authors. We also calculated mortality relative risks. Data were pooled using random-effects models; potential reasons for heterogeneity were explored using subgroup analyses and meta-regressions.

FINDINGS

Twenty-three cohorts contributed data for the pooled all-cause CMR: 1.14 per 100 py [95% confidence interval (CI) = 0.92-1.42]. Pooled cause-specific mortality rates were: drug poisoning, 0.14 per 100 py (95% CI = 0.06-0.34); cardiovascular disease, 0.13 per 100 py (95% CI = 0.06-0.29); suicide, 0.20 per 100 py (95% CI = 0.07-0.55); accidental injury, 0.20 per 100 py (95% CI = 0.08-0.47) and homicide, 0.03 per 100 py (95% CI = 0.02-0.06). There was substantial heterogeneity for all pooled CMR estimates except homicide. The pooled all-cause SMR was 6.83 (95% CI = 5.27-8.84). Pooled cause-specific SMRS were: poisoning, 24.70 (95% CI = 16.67, 36.58); homicide, 11.90 (95% CI = 7.82-18.12); suicide, 12.20 (95% CI = 4.89-30.47); cardiovascular disease, 5.12 (95% CI = 3.74-7.00) and accidental injury, 5.12 (95% CI = 2.88-9.08).

CONCLUSIONS

People with regular or dependent amphetamine use are at elevated risk of a range of causes of mortality compared with people without regular or dependent amphetamine use.

Engagement in treatment for depression among people who inject drugs in Baltimore, Maryland

INTRODUCTION

Mental health care may mitigate negative consequences related to substance use and bolster engagement in care for drug dependence. Despite the increased risk of depression among people who inject drugs (PWID), the longitudinal relationship of depression symptoms with depression and drug treatment utilization in this population remains uncharacterized.

METHODS

Data on depressive symptoms and depression treatment from current and former PWID in the ALIVE (AIDS Linked to the IntraVenous Experience) community-based cohort who had ≥3 study visits from July 2005 to June 2016 were included. We used logistic regression analysis with generalized estimating equations to examine factors associated with depression treatment in the 12 months following reported major depressive symptoms (CES-D ≥ 23) in the absence of treatment. We further examined the association between depression, depression treatment, and subsequent engagement in drug treatment among those with active substance use or alcohol dependence.

RESULTS

Of the 1544 participants, 34% were female, the median age was 51 years, and 91% were African-American. PWID reported major depressive symptoms at 22% of study visits. In adjusted analysis, acute emergency care, suicidal ideation, and recent alcohol or drug treatment were positively associated with initiating depression treatment. Depression was positively associated with subsequent treatment for substance dependence among those actively using (aOR = 1.30, 95% CI: 1.10-1.53).

CONCLUSIONS

PWID experience a high burden of depressive symptoms with significant unmet need of treatment for depression. Our findings suggest that mental health providers should bolster connections to chronic disease and alcohol and drug treatment providers.

Assessment of personality problems among patients with substance use disorders

Aim

Several studies have shown that personality disorders (PDs) are frequently occurring among patients with substance use disorders (SUDs). A development from research of co-occurrence estimates in this patient group investigates personality problems as dimensional constructs, which seek to capture the core of personality pathology. The aim of our study was to explore whether personality problems might be assessed among SUD patients in early stages of treatment. We also sought to investigate personality problem severity among Norwegian adult SUD patients.

Design

Personality problems were assessed using the self-report questionnaire Severity Indices of Personality Problems (SIPP-118). The study sample consisted of 155 SUD patients currently in treatment at detoxification sections at Oslo University Hospital.

Results

Though psychometric evaluation of the SIPP-118, we found that personality problems could be assessed with high levels of internal consistency and convergent validity in SUD patients during detoxification. This is an important contribution to the discussion concerning time and context of personality pathology assessment in the SUD treatment field. The results indicated that SUD patients have personality problems at a level of severity comparable to previously investigated PD patient samples, and significantly more severe than personality problems found in normal population samples. This indicates that personality problems are a common, as well as a detrimental, feature among SUD patients, which further points towards considering these in all aspects of SUD treatment.

Conclusions

Assessing personality problems early in treatment may enable a more integrated approach to SUD treatment targeting personality problems and substance-related problems.

Did you get any help? A post-hoc secondary analysis of a randomized controlled trial of psychoeducation for patients with antisocial personality disorder in outpatient substance abuse treatment programs

BACKGROUND

People in treatment for substance use disorder commonly have comorbid personality disorders, including antisocial personality disorder. Little is known about treatments that specifically address comorbid antisocial personality disorder.

METHODS

Self-rated help received for antisocial personality disorder was assessed during follow-ups at 3, 9 and 15 months post-randomization of a randomized trial of psychoeducation for people with comorbid substance use and antisocial personality disorder (n = 175).

RESULTS

Randomization to psychoeducation was associated with increased perceived help for antisocial personality disorder. Perceived help for antisocial personality disorder was in turn associated with more days abstinent and higher treatment satisfaction at the 3-month follow-up, and reduced risk of dropping out of treatment after the 3-month follow-up, and perceived help mediated the effects of random assignment on days abstinent at 3-month.

FOLLOW-UP

CONCLUSIONS

Brief psychoeducation for antisocial personality disorder increased patients' self-rated help for antisocial personality disorder in substance abuse treatment, and reporting having received help for antisocial personality disorder was in turn associated with better short-term outcomes, e.g., days abstinent, dropout from treatment and treatment satisfaction.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN67266318 , retrospectively registered 17/7/2012.

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.

Trends in cannabis-related ambulance presentations from 2000 to 2013 in Melbourne, Australia

AIMS

The current burden of cannabis-related presentations to emergency health services is largely unknown. This paper presents data collected over a 13-year period in metropolitan Melbourne, Australia as part of the Ambo Project, a unique surveillance system that analyses and codes paramedic records for drug-related trends and harms.

METHODS

Cannabis-related ambulance attendances involving 15-59 year olds in metropolitan Melbourne were analysed retrospectively from 2000 to 2013 (n=10,531). Trends and attendance characteristics were compared among cannabis only (CO)-, cannabis and alcohol (CA)- and cannabis with polydrug use (CP)-related attendances. Changes in alcohol and drug involvements in cannabis-related attendances were explored.

RESULTS

Rates of cannabis-related ambulance attendances increased significantly over the study period. Increasing rate of attendances per 100,000 population per year changed from 0.6 (2000-2010) to 5.5 (2010-2013). This sharp change was driven by CO- and CP-related attendances (rate of CA-related attendance increased steadily). The highest increasing rate (15.6) was for CO-related attendances among 15-29 years old males (2010-2013). Crystal methamphetamine became the most common illicit co-intoxicant amongst cannabis presentations in 2013.

CONCLUSIONS

Relative to the total drug-related burden on ambulance services, cannabis-related presentations appear to be a small but significant and increasing problem. Significant changes in trends across other drug involvement and demographic subgroups suggest a possible shift in the cannabis using population and/or a change in using behaviours. Public health strategies should raise awareness of the increased risk posed by cannabis polydrug use and high attendance subpopulations should be determined.

Mortality, causes of death, and health status among methamphetamine users

This study examines causes of death, years of life lost, and health and drug use characteristics associated with mortality over an 8 to 10 year period in a sample of methamphetamine users who had and had not received substance use disorder treatment (N = 563). Decedents reported initiating their methamphetamine use for different reasons than surviving methamphetamine users, and some of these differences varied by treatment status. Study findings provide additional detail on long-term health and mortality outcomes in a diverse sample of methamphetamine users, which may inform public health strategies targeting the comparable and divergent needs of treated and untreated populations.

Mortality, causes of death and risk factors for death among primary amphetamine users in the Swedish criminal justice system

This study examined mortality and predictors of death in 1,396 primary amphetamine users (85% males) who were interviewed with the Addiction Severity Index in the Swedish criminal justice system during 2000-2006 and followed through 2008. Forty-nine clients deceased (standardized mortality ratio 4.1 [3.0-5.4]), at least 84% of deaths were violent or drug-related (12% suicides), and Cox regression analysis indicated that death was associated with frequent use of sedatives and less frequent use of amphetamine. No female deaths were observed; death and male gender were associated in binary analysis. Implications for diagnostics and treatment are discussed.

Attention deficit/hyperactivity disorders with co-existing substance use disorder is characterized by early antisocial behaviour and poor cognitive skills

BACKGROUND

Attention Deficit/Hyperactivity Disorder (ADHD) is associated with an increased risk of co-existing substance abuse. The Swedish legislation on compulsory healthcare can be applied to persons with severe substance abuse who can be treated involuntarily during a period of six months. This context enables a reliable clinical assessment of ADHD in individuals with severe substance use disorder (SUD).

METHODS

In the context of compulsory care for individuals with severe SUD, male patients were assessed for ADHD, co-morbid psychiatric symptoms, psychosocial background, treatment history, and cognition. The data from the ADHD/SUD group (n = 60) was compared with data from (1) a group of individuals with severe substance abuse without known ADHD (SUD group, n = 120), as well as (2) a group with ADHD from an outpatient psychiatric clinic (ADHD/Psych group, n = 107).

RESULTS

Compared to the general SUD group in compulsory care, the ADHD/SUD group had already been significantly more often in compulsory care during childhood or adolescence, as well as imprisoned more often as adults. The most common preferred abused substance in the ADHD/SUD group was stimulant drugs, while alcohol and benzodiazepine abuse was more usual in the general SUD group. Compared to the ADHD/Psych group, the ADHD/SUD group reported more ADHD symptoms during childhood and performed poorer on all tests of general intellectual ability and executive functions.

CONCLUSIONS

The clinical characteristics of the ADHD/SUD group differed from those of both the SUD group and the ADHD/Psych group in several respects, indicating that ADHD in combination with SUD is a particularly disabling condition. The combination of severe substance abuse, poor general cognitive ability, severe psychosocial problems, including indications of antisocial behaviour, and other co-existing psychiatric conditions should be considered in treatment planning for adults with ADHD and SUD.

Which factors influence psychiatric diagnosing in substance abuse treatment?

Background

The importance of diagnosing and treating co-occurring psychiatric disorders among substance abusers in treatment has received much attention. The aim of this study was to investigate to which extent co-occurring psychiatric disorders are diagnosed in a clinical population of substance abusers, and which factors (including the use of MINI-Plus) that influence the diagnosing of co-occurring psychiatric disorders.

Methods

Patients (N = 275) who received inpatient substance use treatment in five different units in Northern Norway participated in the study. The patients’ clinicians gave information on diagnoses given during the stay in the units, and whether a systematic diagnostic tool was used for the diagnosing (MINI-Plus). Predictors of independent co-occurring psychiatric disorders were examined utilizing hierarchical regression analysis.

Results

One third of the patients were given an independent psychiatric diagnosis. Less than half of the patients were assessed using a diagnostic tool. The main predictor of diagnosing of independent psychiatric disorders was the use of the diagnostic tool MINI-Plus. Younger patients and patients that used less alcohol, were given independent psychiatric diagnoses more frequently.

Conclusions

The number of co-occurring independent psychiatric diagnoses was lower compared to other studies using standardized diagnostic tools. The low number of patients assessed by such a tool, and the strong relationship between the use of such a tool and the diagnosing of co-occurring psychiatric disorders, suggest that the implementation of standardized diagnostic tools should be addressed in the units. Generally, patients suffering from substance use disorders should be systematically screened for other psychiatric disorders, in order to improve their treatment and health.

Ethical Considerations in Deep Brain Stimulation for the Treatment of Addiction and Overeating Associated With Obesity

The success of deep brain stimulation (DBS) for movement disorders and the improved understanding of the neurobiologic and neuroanatomic bases of psychiatric diseases have led to proposals to expand current DBS applications. Recent preclinical and clinical work with Alzheimer's disease and obsessive-compulsive disorder, for example, supports the safety of stimulating regions in the hypothalamus and nucleus accumbens in humans. These regions are known to be involved in addiction and overeating associated with obesity. However, the use of DBS targeting these areas as a treatment modality raises common ethical considerations, which include informed consent, coercion, enhancement, threat to personhood, and manipulation of the reward center. Pilot studies for both of these conditions are currently investigational. If these studies show promise, then there is a need to address the ethical concerns related to the initiation of clinical trials including the reliability of preclinical evidence, patient selection, study design, compensation for participation and injury, cost-effectiveness, and the need for long-term follow-up. Multidisciplinary teams are necessary for the ethical execution of such studies. In addition to establishing safety and efficacy, the consideration of these ethical issues is vital to the adoption of DBS as a treatment for these conditions. We offer suggestions about the pursuit of future clinical trials of DBS for the treatment of addiction and overeating associated with obesity and provide a framework for addressing ethical concerns related to treatment.

A 25-year follow-up of patients admitted to methadone treatment for the first time: mortality and gender differences

INTRODUCTION

We conducted a follow-up study to evaluate the outcome of a heroin-dependent population 25 years after their first enrollment in methadone maintenance treatment (MMT). We assessed mortality in the sample plus actual drug use, treatment, and medical factors associated with drug dependence, focusing on possible gender differences.

METHODS

Prospective follow-up study of 214 heroin-dependent patients consecutively admitted for MMT between 1980 and 1984 in the Asturias Public Health Service. The standardized mortality ratio (SMR) and 95% confidence interval (CI) were calculated. An ad-hoc protocol on drug misuse and treatment, drug-related morbidity and Clinical Global Impression (CGI) scores were assessed in the survivors' sample.

RESULTS

Information was received on 159 subjects, 106 of whom were deceased. Men accounted for 76.2% of the study cohort. Over the 25-year follow-up period, the SMR was 22.51 (95% CI=22.37-22.64). In the survivors sample, 39.6% were still enrolled in MMT; human immunodeficiency virus (HIV) was diagnosed in 47.2% and hepatitis B/C in 81.1%; current heroin use was reported by 22.6%. There were no gender differences in mortality or HIV and hepatitis B/C status. None of the female survivors were using heroin at the 25-year follow-up compared with 31.1% of males.

CONCLUSIONS

This study confirms the high mortality of heroin addicts even after enrollment in MMT. Severity of the addiction in terms of mortality was similar in both genders. Women who survived the 25-year follow-up were more likely to have stopped using heroin than men.

Substance abuse and psychiatric co-morbidity as predictors of premature mortality in Swedish drug abusers: a prospective longitudinal study 1970-2006

BACKGROUND

Few longitudinal cohort studies have focused on the impact of substances abused and psychiatric disorders on premature mortality. The aim of the present study was to identify predictors of increased risk of drug related death and non drug related death in substance abusers of opiates, stimulants, cannabis, sedatives/hypnotics, hallucinogens and alcohol over several decades.

METHODS

Follow-up study of a consecutive cohort of 561 substance abusers, admitted to a detoxification unit January 1970 to February 1978 in southern Sweden, and followed up in 2006. Demographic and clinical data, substance diagnoses and three groups of psychiatric diagnoses were identified at first admission. Causes of death were coded according to ICD-10 and classified as drug related deaths or non drug related deaths. To identify the incidence of some probable risk factors of drug related premature death, the data were subjected to a competing risks Cox regression analysis.

RESULTS

Of 561 patients in the cohort, 11 individuals had either emigrated or could not be located, and 204/561 patients (36.4%) were deceased by 2006. The cumulative risk of drug related death increased more in the first 15 years and leveled out later on when non drug related causes of death had a similar incidence. In the final model, male gender, regular use of opiates or barbiturates at first admission, and neurosis were associated with an increased risk of drug related premature death, while cannabis use and psychosis were associated with a decreased risk. Neurosis, mainly depression and/or anxiety disorders, predicted drug related premature death while chronic psychosis and personality disorders did not. Chronic alcohol addiction was associated with increased risk of non drug related death.

CONCLUSIONS

The cohort of drug abusers had an increased risk of premature death to the age of 69. Drug related premature death was predicted by male gender, the use of opiates or barbiturates and depression and anxiety disorders at first admission. The predicted cumulative incidence of drug related death was significantly higher in opiate and barbiturate abusers over the observed period of 37 years, while stimulant abuse did not have any impact. Alcohol contributed to non drug related death.

Poly-substance use and antisocial personality traits at admission predict cumulative retention in a buprenorphine programme with mandatory work and high compliance profile

BACKGROUND

Continuous abstinence and retention in treatment for alcohol and drug use disorders are central challenges for the treatment providers. The literature has failed to show consistent, strong predictors of retention. Predictors and treatment structure may differ across treatment modalities. In this study the structure was reinforced by the addition of supervised urine samples three times a week and mandatory daily work/structured education activities as a prerequisite of inclusion in the program.

METHODS

Of 128 patients consecutively admitted to buprenorphine maintenance treatment five patients dropped out within the first week. Of the remaining 123 demographic data and psychiatric assessment were used to predict involuntary discharge from treatment and corresponding cumulative abstinence probability. All subjects were administered the Structured Clinical Interview for DSM-IV-TR, and the Symptom Checklist 90 (SCL-90), the Alcohol Use Disorder Identification Test (AUDIT), the Swedish universities Scales of Personality (SSP) and the Sense of Coherence Scale (SOC), all self-report measures. Some measures were repeated every third month in addition to interviews.

RESULTS

Of 123 patients admitted, 86 (70%) remained in treatment after six months and 61 (50%) remained in treatment after 12 months. Of those discharged involuntarily, 34/62 individuals were readmitted after a suspension period of three months. Younger age at intake, poly-substance abuse at intake (number of drugs in urine), and number of conduct disorder criteria on the SCID Screen were independently associated with an increased risk of involuntary discharge. There were no significant differences between dropouts and completers on SCL-90, SSP, SOC or AUDIT.

CONCLUSION

Of the patients admitted to the programme 50% stayed for the first 12 months with continuous abstinence and daily work. Poly-substance use before intake into treatment, high levels of conduct disorder on SCID screen and younger age at intake had a negative impact on retention and abstinence.

Causes of premature mortality in Swedish drug abusers: a prospective longitudinal study 1970-2006

AIMS

To evaluate premature mortality and causes of death from young adulthood to middle age in a cohort of drug users followed during almost four decades.

DESIGN

Follow-up study of a consecutive cohort of patients with drug abuse/dependence.

METHODS

A cohort of 561 drug abusers, admitted to a detoxification and short-term rehabilitation unit 1970-1978 was followed to December 31st, 2006. Standardized interviews and hospital records with toxicological analyses were used for demographic data, substance use and psychiatric diagnoses at admission. For Follow-up analyses, autopsy protocols including toxicology tests and death certificates were obtained for assessment of causes of death which were coded according to ICD-10. Age-group standardized mortality ratios were calculated independently for both sexes.

RESULTS

204 persons (36.4%) were deceased by 2006. SMR was 5.94 for the cohort. Compared to an age- and gender-matched population, the risk of premature death was about eighteen times higher between the ages of 20-44 and about five times higher from 45 up to the age of 69. Of 120 (59%) drug-related deaths, 43 were opiate overdoses, and 3 were overdose from amphetamine. A total of 53 (26%) persons died violent deaths: 39 suicides, of which 25 were drug-related, 3 homicides and 12 accidents. The Swedish national causes of death register underestimated drug-related death by 37% and suicide by 85% compared to the results from this study.

CONCLUSIONS

The cohort of drug abusers had an increased risk of premature often drug-related and violent death well into middle age, and to a great extent the drug addicts died from the same drug they had abused when they were first admitted for treatment. The underestimation of drug-related death and suicide in some national death cause registers could be reduced if the doctor routinely records ICD codes when issuing death certificates and autopsy protocols.

Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies

AIMS

To review the literature on mortality among dependent or regular users of opioids across regions, according to specific causes, and related to a number of demographic and clinical variables.

METHODS

Multiple search strategies included searches of Medline, EMBASE and PsycINFO, consistent with the methodology recommended by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group; grey literature searches; and contact of experts for any additional unpublished data from studies meeting inclusion criteria. Random-effects meta-analyses were conducted for crude mortality rates (CMRs) and standardized mortality ratios (SMRs), with stratified analyses where possible. Meta-regressions examined potentially important sources of heterogeneity across studies.

RESULTS

Fifty-eight prospective studies reported mortality rates from opioid-dependent samples. Very high heterogeneity across studies was observed; pooled all-cause CMR was 2.09 per 100 person-years (PY; 95% CI; 1.93, 2.26), and the pooled SMR was 14.66 (95% CI: 12.82, 16.50). Males had higher CMRs and lower SMRs than females. Out-of-treatment periods had higher mortality risk than in-treatment periods (pooled RR 2.38 (CI: 1.79, 3.17)). Causes of death varied across studies, but overdose was the most common cause. Multivariable regressions found the following predictors of mortality rates: country of origin; the proportion of sample injecting; the extent to which populations were recruited from an entire country (versus subnational); and year of publication.

CONCLUSIONS

Mortality among opioid-dependent users varies across countries and populations. Treatment is clearly protective against mortality even in non-randomized observational studies. Study characteristics predict mortality levels; these should be taken into account in future studies.

Mortality and employment after in-patient opiate detoxification

AIM

We considered that completed opiate detoxification resulted in increased life expectancy and earning capacity as compared to non-completed detoxification.

METHODS

The cohort study sample included pure opioid or poly-substance addicts admitted for voluntary in-patient detoxification between 1997 and 2004. Of 404 patients, 58.7% completed the detoxification program and 41.3% did not. The Austrian Social Security Institution supplied data on survival and employment records for every single day in the individual observation period between discharge and December 2007. Statistical analyses included the calculation of standardized mortality rates for the follow-up period of up to 11 years.

RESULTS

The standardized mortality ratios (SMRs) were between 13.5 and 17.9 during the first five years after discharge, thereafter they fell clearly with time. Mortality did not differ statistically significantly between completers and non-completers. The median employment rate was insignificantly higher in completers (12.0%) than in non-completers (5.5%). The odds for being employed were higher in pure opioid addicts than in poly-substance addicts (p=0.003).

CONCLUSIONS

The assumption that completers of detoxification treatment have a better outcome than non-completers has not been confirmed. The decrease in mortality with time elapsed since detoxification is interesting. Pure opioid addicts had better employment prospects than poly-substance addicts.

Psychiatric distress, risk behavior, and treatment enrollment among syringe exchange participants

The present study evaluated psychiatric distress as a predictor of treatment enrollment in out-of-treatment injection opioid users newly registered at the Baltimore Needle Exchange Program (BNEP). Study participants (n=281) completed the Addiction Severity Index (ASI), the Risk Assessment Battery (RAB), and the Symptom Checklist-90 (SCL-90-R), and were randomly assigned to one of three different conditions for 4 months that evaluated referral strategies designed to promote treatment interest and enrollment. The Global Severity Index (GSI) of the SCL-90 was used as a measure of psychiatric distress. A logistic regression showed that higher GSI scores predicted more treatment enrollment (Adjusted OR=2.15, CI=1.10-4.23, p<0.05), after controlling for study condition, demographic variables, syringe exchange site, and severity of drug use. The results suggest that the data from the assessment of psychiatric distress in syringe exchange settings can be used to support motivational strategies for encouraging syringe exchangers to seek substance abuse treatment.

Mortality among amphetamine users: a systematic review of cohort studies

AIMS

To report the results of a comprehensive literature search of studies of mortality among people who use amphetamines.

DESIGN AND SETTING

Three electronic databases were searched (EMBASE, Medline and PsycINFO) and "grey" literature was located. Shortlists of papers were circulated to experts to ascertain whether any important papers had been missed. Papers were hand-searched to retrieve any additional relevant articles.

MEASUREMENTS

Studies meeting inclusion criteria were prospective cohort studies examining mortality risk among dependent and problematic amphetamine users. Crude mortality rates (CMR/100PY) and standardised mortality ratios (SMRs) were the primary outcome measures considered. Data on overall mortality, and rates for specific causes of death, were of interest.

FINDINGS

2187 articles and 9 grey literature sources were obtained. After thorough review, 72 articles were identified as reporting on amphetamine-related mortality, 7 provided data from cohort studies of users. An additional study of Swedish military conscripts was identified by the authors during correspondence with other researchers. The geographic spread of cohorts was restricted to high income countries with the exception of one Thai study; reporting of standard parameters in mortality studies was often sparse. The estimated CMRs ranged from 0 in Australia to 2.95 (1.46-4.59) in Thailand. The Czech cohort reported the only SMR: 6.22 overall, males: 5.87, females: 7.84.

CONCLUSIONS

Given the widespread use of amphetamines, the known non-fatal adverse effects of use and the mortality rates reported here, cohort studies investigating the morbidity and mortality associated with such drug use should be a research priority.

Sense of coherence in Crete and Sweden: key findings and messages from a comparative study

BACKGROUND/OBJECTIVE

The concept of ''sense of coherence'' (SOC) was introduced in 1987 by Aaron Antonovsky to describe a dispositional orientation, ''a way of seeing the world'', which is presumed to enhance health. This study reports on the results of the first implementation of SOC in rural Crete and discusses the findings, with a view to the potential impact on primary care delivery in rural Crete.

METHODS

This study forms part of a follow-up project initially established in 1988 in the rural area of Spili, Crete. All participants of the initial study still living in the area (n = 248) were eligible. Data were obtained from 200 subjects (91 males and 109 females) aged 28-92 years, resulting in a second-phase participation rate of 80.7%. The SOC scales (both the SOC-29 and SOC-13 forms) were recorded for 175 (87.1%) of the participants.

RESULTS

Comparing the SOC scores among Cretan males and females, there is a statistically significant difference (p < 0.0001), with men reporting a higher sense of coherence than women, regardless of the form of the questionnaire used. Cretan women seem to score significantly lower than their Swedish counterparts (p < 0.0001), while Cretan men tend to report a higher SOC compared to their matched Swedish reference population (p = 0.07).

DISCUSSION

The study introduces other issues worthy of additional research, particularly with regard to the significantly lower SOC scores obtained by Cretan women, compared to Cretan men. These low SOC scores raise the issue of a potential increase of psychiatric morbidity in the area, leading to a high impact on primary care services. Future investigation into the health impact of SOC factors could be of value to primary care physicians located in rural Crete.

Premature mortality among males with substance use disorders

OBJECTIVE

Previous studies have demonstrated that substance use disorders (SUD) are associated with premature mortality in clinical populations, though findings regarding the effect of antisocial personality disorder (ASP) on mortality among persons with SUD are less clear. However, it is unclear to what extent that finding generalizes to persons with SUD in the community, because very little work has been done involving mortality in longitudinal studies of mortality associated with SUD. The objective of this study was to assess whether the presence of SUD or ASP is associated with early mortality among males (fathers) in a predominantly community sample, using a 15-year prospective longitudinal study design.

METHOD

We conducted a prospective longitudinal study of adolescents and their fathers. The adolescent subjects were recruited at age 10-12 years, with follow-up evaluations at ages 14, 16, 19, 22, and 25. Questions were asked about paternal mortality during each of those visits. The study sample for this study was the 769 fathers of the adolescent subjects, who included N=341 fathers with a DSM-III-R diagnosis of SUD and N=428 control fathers without a SUD. 89% of these fathers were recruited from the community, and 11% were recruited from clinical sources. Comorbidity patterns were described. A multivariate Cox regression analysis was performed with the father's age at death or last assessment as the dependent variable, and education, SUD, and ASP as the independent variables.

RESULTS

Lower education level, the presence of a substance use disorder, and the presence of antisocial personality disorder were significantly associated with earlier mortality (Wald=5.1, df=1, p=0.024; Wald=5.1, df=1, p=0.024, and Wald=5.5, df=1, p=0.019, respectively). Most subjects died from medical illnesses, as opposed to drug overdoses or accidents, which is different from the pattern often noted in clinical samples.

CONCLUSIONS

The results of this study demonstrate that the presence of SUD, the presence of ASP, and a lower education level were associated with early mortality in our primarily community-based sample, which extends previous reports of similar findings in clinical samples. The magnitude of the prematurity of the deaths was less that that generally noted in previous studies involving clinical samples, and the causes of death were also somewhat different from those noted in clinical samples. The majority of cases of mortality in our SUD sample resulted from medical illnesses rather than from accidents or overdoses.

Feasibility and acceptability of a mental health screening tool and training programme in the youth alcohol and other drug (AOD) sector

The high prevalence of co-occurring mental health and substance use disorders in young people is well established. Despite this, there are low rates of detection of co-occurring disorders across alcohol and other drug (AOD) services within Australia. This paper describes the development, implementation and evaluation of a mental health screening tool and training programme within the youth AOD sector. Thirty youth AOD workers received training in mental health screening, and the screening tool was subsequently piloted on 84 young people accessing two youth AOD services. Training was evaluated using measures of the trainee's mental health knowledge, attitudes, skills and confidence in mental health screening at baseline and 12-month follow-up. Feedback from young people supported the feasibility, acceptability and relevance of the screening tool. Evaluation of the associated training programme indicated improvements in AOD workers' mental health knowledge, skills and confidence in mental health screening. These findings provide preliminary evidence of the feasibility and acceptability of the mental health screening tool to young people and the effectiveness of the training package within the youth AOD sector.

Being close and being social: peer ratings of distinct aspects of young adult social competence

The present study had three main objectives: (1) to develop and validate scales of young adult social competence in two domains, close relationships and social groups, using peer ratings of California Q-sort (Block, 1974; Kremen & Block, 2002) items; (2) to test the hypothesis that social competence is associated with young adult well-being and ego development; (3) to test the hypothesis that close relationship competence aligns more closely than social group competence with young adult functioning. Psychometric data on peer ratings of social competence are presented. For 133 young adults, peer ratings of social competence were correlated in expected directions with indices of functioning (e.g., self-worth, education, psychological distress, criminal behavior, and ego development). Associations were generally stronger for competence in close relationships than in social groups.

Patients with addiction and personality disorder: Treatment outcomes and clinical implications

PURPOSE OF REVIEW

The present review examines the outcomes of treatments focusing on substance abuse, on personality disorders, and on both the foci simultaneously. Clinical guidelines for the treatment of dually diagnosed patients are described.

RECENT FINDINGS

Recent studies continued the tradition of examining the importance of factors such as the chronicity of substance abuse and the impact of sex with regard to the prognosis of the treatment of substance abuse and the development of effective treatment programs. Overall, the multifaceted and risky nature of dual problems is stressed, and as a logical consequence, an early detection of dual problems is promoted. Several studies show the risk of suicidal and harmful behavior associated with this population, even when the treatment for substance abuse has been successful. For the first time, the issue of dropout is studied from the client's perspective.

SUMMARY

Knowledge about the effectiveness of dually focused treatments is emerging. Results show that the treatment of dually diagnosed patients with severe problems needs to include both the foci because it leads to enormous gains for the patients when personality disorders are also addressed. Yet, integrated treatment programs are lacking and research is still too limited.