Is recreational ecstasy (MDMA) use associated with higher levels of depressive symptoms?

Comparing ecstasy users and non-users in a population-based and co-twin control design across multiple traits

OBJECTIVE

Ecstasy is one of the most commonly used illicit substances in Western countries. The aim of this study is to identify characteristics of ecstasy users in a large population-based sample of adults aged 18-45 years.

METHOD

With generalized estimating equation models we explored the association between self-reported lifetime ecstasy use and urbanicity, educational attainment, health, wellbeing, stress, other substance use, personality traits and psychopathology in a Dutch twin sample (N = 9578, 66.8% female, 18-45 years). We also explored the nature of the association (underlying genetic factors, shared environmental factors or a causal relationship) with the co-twin control method.

RESULTS

Lifetime ecstasy users (N = 945, 9.9%) were more often male, younger, living more often in urban areas, higher educated, less satisfied with life and more stressed than non-users. Ecstasy users scored differently on most personality and psychopathology scales compared to non-users and were more likely to have used every other substance we investigated. Whereas smoking tobacco and alcohol use often preceded first use of ecstasy, first ecstasy use often preceded first use of other illicit substances. A combination of scenarios (both causal and environmental/genetic) explained the strong associations between ecstasy and substance use.

CONCLUSIONS

Ecstasy users differ on many characteristics from non-users, and especially on illicit substance use. Our results indicate that causal effects may play a role in explaining the relationship between ecstasy use and other illicit substance use.

Using population screening for recruitment of young adults engaged in illicit drug use: methodological issues and sampling outcomes

Social stigma, legal sanctions and the associated lack of sampling frames create barriers to the probabilistic sampling of those engaged in a variety of behaviour, including illicit drug use. We used a novel sampling approach to recruit respondents into a longitudinal study examining amphetamine-type stimulant use. A young adult population was screened for lifetime drug use to create a sampling frame of amphetamine-type stimulant users and non-users. We posted 12,118 screening questionnaires to a random selection of young adults listed on the electoral roll for Brisbane and the Gold Coast, Australia (N=107,275). Using a small pre-paid incentive and intensive telephone and postal reminders we attained a screening response rate of 49.9%. Eligible amphetamine-type stimulant users (used ecstasy or methamphetamine⩾3 times in past 12 months) and non-users (never used ecstasy or methamphetamine) were identified by screening responses. About two-thirds of each selected group took part in the longitudinal study. Comparisons with large-scale population survey data suggest the sample was broadly representative of young adult amphetamine-type stimulant users in Australia.

Psychological Distress and Drug Use Patterns of Young Adult Ecstasy Users: A Complementary Analysis of Australian Datasets

We examine psychological distress (PD) in young adult Ecstasy users in relation to age of initiation and frequency of use of Ecstasy, cannabis, alcohol, and tobacco. Using two Australian community samples, we assess whether different sampling methods produce comparable estimates of these associations. The Natural History Study of Drug Use (NHSDU; N = 339) in 2009 used population sampling and the 2009 Ecstasy and Related Drug Reporting System (EDRS; N = 359) used purposive sampling. Participants, aged 19-23 years, were recurrent Ecstasy users. PD was assessed using Kessler 10 in the EDRS and Hospital Anxiety Depression Scale in the NHSDU. In both samples, PD was associated with daily tobacco use and early drug initiation, but not frequent Ecstasy use. One-third smoke tobacco daily. Study limitations and implications are noted.

3,4-methylenedioxymethamphetamine (MDMA): current perspectives

Ecstasy is a widely used recreational drug that usually consists primarily of 3,4-methylenedioxymethamphetamine (MDMA). Most ecstasy users consume other substances as well, which complicates the interpretation of research in this field. The positively rated effects of MDMA consumption include euphoria, arousal, enhanced mood, increased sociability, and heightened perceptions; some common adverse reactions are nausea, headache, tachycardia, bruxism, and trismus. Lowering of mood is an aftereffect that is sometimes reported from 2 to 5 days after a session of ecstasy use. The acute effects of MDMA in ecstasy users have been attributed primarily to increased release and inhibited reuptake of serotonin (5-HT) and norepinephrine, along with possible release of the neuropeptide oxytocin. Repeated or high-dose MDMA/ecstasy use has been associated with tolerance, depressive symptomatology, and persisting cognitive deficits, particularly in memory tests. Animal studies have demonstrated that high doses of MDMA can lead to long-term decreases in forebrain 5-HT concentrations, tryptophan hydroxylase activity, serotonin transporter (SERT) expression, and visualization of axons immunoreactive for 5-HT or SERT. These neurotoxic effects may reflect either a drug-induced degeneration of serotonergic fibers or a long-lasting downregulation in 5-HT and SERT biosynthesis. Possible neurotoxicity in heavy ecstasy users has been revealed by neuroimaging studies showing reduced SERT binding and increased 5-HT_2A receptor binding in several cortical and/or subcortical areas. MDMA overdose or use with certain other drugs can also cause severe morbidity and even death. Repeated use of MDMA may lead to dose escalation and the development of dependence, although such dependence is usually not as profound as is seen with many other drugs of abuse. MDMA/ecstasy-dependent patients are treated with standard addiction programs, since there are no specific programs for this substance and no proven medications. Finally, even though MDMA is listed as a Schedule I compound by the Drug Enforcement Agency, MDMA-assisted psychotherapy for patients with chronic, treatment-resistant posttraumatic stress disorder is currently under investigation. Initial results show efficacy for this treatment approach, although considerably more research must be performed to confirm such efficacy and to ensure that the benefits of MDMA-assisted therapy outweigh the risks to the patients.

Ecstasy use and depression: a 4-year longitudinal study among an Australian general community sample

RATIONALE

Longitudinal, population-based studies can better assess the relationship of ecstasy use with depression.

OBJECTIVES

We examined whether change in ecstasy use was associated with change in depressive symptoms/probable depression over a 4-year period, among a large Australian sample.

METHODS

The Personality and Total Health project is a longitudinal general community study of Australians from Canberra and Queanbeyan. Data from the youngest cohort when aged 24-30 (N = 2, 128) and 4 years later (N = 1, 977) was included. The Goldberg depression scale and the Brief Patient Health Questionnaire measured depressive symptoms and probable depression, respectively. Multilevel growth models also considered demographics, psychosocial characteristics, and other drug use.

RESULTS

Ecstasy use was not associated with long-term depressive symptoms or greater odds of depression in multivariate analyses. Users had more self-reported depressive symptoms when using ecstasy compared to not using. However, differences between people who had and had not ever used ecstasy largely accounted for this. Other factors were more important in the prediction of depression.

CONCLUSIONS

It would be premature to conclude that ecstasy use is not related to the development of long-term depressive symptoms, given the relatively low level of ecstasy and other drug use in this community sample. Results showed that other factors need to be considered when investigating ecstasy use and depression.

Ecstasy use and suicidal behavior among adolescents: findings from a national survey

The relationship between ecstasy use and suicidal behavior among adolescents in the United States was examined. Data from the adolescent subsample (ages 12-17, N = 19,301) of the 2000 National Household Survey on Drug Abuse were used in the analyses. Information on adolescent substance use, suicidal behaviors, and related sociodemographic, family, and individual factors was obtained in the survey. The rate of past year suicide attempt among adolescents with lifetime ecstasy use was almost double that of adolescents who had used other drugs only, and nine times that of adolescents with no history of illicit drug use. In multinomial logistic regression analyses controlling for related factors, the effect of ecstasy use remained significant. Adolescent ecstasy users may require enhanced suicide prevention and intervention efforts.

Comorbid psychiatric diagnoses among individuals presenting to an addiction treatment program for alcohol dependence

A retrospective patient record review was conducted to examine comorbid psychiatric diagnoses, and comorbid substance use, among 465 patients below 45 years of age, presenting to a national alcohol addiction treatment unit in Dublin, between 1995 and 2006. Rates were high for depressive disorder (25.3%) particularly among females (35.4%). Lifetime reported use of substances other than alcohol was 39.2%, and further analysis showed significantly higher rates of deliberate self-harm among this group. Lifetime reported use of ecstasy was also significantly associated with depression in this alcohol-dependent population using logistic regression analysis. Implications and limitations of the findings are discussed.

Acute tryptophan depletion potentiates 3,4-methylenedioxymethamphetamine-induced cerebrovascular hyperperfusion in adult male Wistar rats

The serotonergic (5-hydroxytryptamine; 5-HT) dysfunction found in depression may affect not only brain function (mood) but also cerebrovascular control. Similar, but possibly occult, disturbances may also be induced by 3,4-methylenedioxymethamphetamine-induced neurotoxicity (MDMA, or "ecstasy"). Acute tryptophan depletion (ATD) is widely used to identify vulnerability to depression, and we hypothesized that repeated MDMA administration would increase the sensitivity of rats to this acute serotonergic challenge. In this study, male Wistar rats were injected with MDMA (20 mg kg(-1), twice daily for 4 days) and challenged 3 weeks later with ATD, induced by intragastric administration of a nutritional mixture with tryptophan (TRP) removed. Cerebral metabolism (CMRG) and blood flow (CBF) were measured in parallel groups of animals following ATD by using quantitative [(14)C]2-deoxyglucose and [(14)C]iodoantipyrine autoradiographic techniques, respectively. A significant reduction in paroxetine binding to 5-HT transporter sites in MDMA-treated rats indicated 5HT terminal depletion, whereas the plasma TRP/sum large neutral amino acids ratio was reduced by 40% following ATD. Under all experimental conditions, the normal close correlation between CBF and metabolic demand was maintained. However, a global analysis of all brain regions revealed a significant decrease in the overall ratio of CBF to CMRG after ATD in control animals, whereas a higher ratio was observed after ATD in the MDMA-treated group. This increase in blood flow relative to cerebral metabolism suggests an ATD-induced loss of cerebrovascular tone in MDMA-treated animals that could have pathophysiological consequences and might conceivably contribute to the behavioral dysfunction of depression.

Long-term neuropsychological effects of ecstasy in middle-aged ecstasy/polydrug users

RATIONALE

Studies reporting ecstasy-induced serotonin-toxicity and (neuro)psychological dysfunctions have been conducted in young adults. Little is known about ecstasy effects later in life, when serotonin levels and cognition decrease as a consequence of normal ageing.

OBJECTIVE

This study aimed to assess whether harmful effects of ecstasy only add to or also interact with age-related neuropsychological decline.

METHODS

Attention, verbal and visual memory, visuospatial ability, self-reported depression, sensation-seeking and impulsivity were assessed in middle-aged moderate to heavy ecstasy/polydrug users (n = 17) and compared with none or very mild ecstasy using polydrug users (matched for age, gender, intelligence and other drugs; n = 16) and a group of drug-naive controls (n = 20).

RESULTS

Moderate to heavy ecstasy/polydrug users performed significantly worse on a verbal memory task than none or very mild ecstasy using polydrug users and drug naives. Moderate and heavy ecstasy/polydrug users also differed significantly from drug-naives on measures of depression, sensation-seeking and impulsivity but not from none or very mild ecstasy-using polydrug users.

CONCLUSION

This study in middle-aged ecstasy/polydrug users replicated findings of studies in younger ecstasy users, showing a harmful effect of ecstasy on verbal memory. There was no clear support for an interaction between harmful effects of ecstasy use and age-related memory decline or mid-life depression.

Morbidity in a population of low-income, female users of MDMA and other drugs

Few previous studies have reported on the overall health of drug-using women. To investigate this, 696 low-income women aged 18-31 were recruited in a cross-sectional study from gynecological care clinics in Texas between 2001 and 2003. Compared to exclusive marijuana users and non-drug users, women who used MDMA and those who used other illicit drugs but not MDMA reported more gynecological conditions, medical conditions, depressive symptoms, and physical somatic complaints. We concluded that young, low-income women who used more than one illicit drug experience significantly more physical and psychological morbidity. Generalization of this study results may be limited to young women with low income but not to other populations.