Prevalence and predictors of psychopathology among opioid users

Predictive Outcome Validity of General Health Questionnaire (GHQ-28) in Substance Abuse Patients Treated in Therapeutic Communities

Objective: The use of psychoactive substances has been one of the most important global public health problems over the last few decades. Among the problems associated with substance use, dual diagnosis is one of the most relevant. This study aims to investigate the predictive validity of the GHQ-28 (General Health Questionnaire-28; "probable psychiatric cases") in relation to poor treatment outcome measured by (a) "early treatment dropout" and (b) "nonclinically relevant improvement at discharge." Methods: A longitudinal prospective design was used. A sample of 219 substance use disorder patients, who received treatment in a therapeutic community, was selected. Patients were assessed using the GHQ-28 and the outcome variables were registered. A hierarchical logistic regression model was performed to identify factors independently associated with the outcome measure ("early treatment dropout" and "nonclinically relevant improvement at discharge"). Results: Of the total sample, 79 subjects (36%) were considered "early treatment dropouts" and 56.6% (102) presented a "nonclinically relevant improvement at discharge." The two hierarchical logistic regression results show that being classified as a "probable psychiatric case" was significantly and directly associated with "early treatment dropout" and "nonclinically relevant improvement at discharge," as a poor in-treatment outcome indicator. Conclusions: The results of this study support the notion that the probable psychiatric cases identified by the GHQ-28 scale have a greater probability of "early treatment dropout" and have a greater probability of "nonclinically relevant improvement in discharge" of the therapeutic community. These data indicate that GHQ-28 is a suitable clinical instrument for predicting dropout and treatment effect in residential substance use disorder treatment.

Social cognition impairments in long-term opiate users in treatment

BACKGROUND

Long-term opiate users experience pervasive social difficulties, but there has been surprisingly limited research focused on social-cognitive functioning in this population.

AIM

The aim of this study was to investigate whether three important aspects of social cognition (facial emotion recognition, theory of mind (ToM) and rapid facial mimicry) differ between long-term opiate users and healthy controls.

METHODS

The participants were 25 long-term opiate users who were enrolled in opiate substitution programmes, and 25 healthy controls. Facial emotion recognition accuracy was indexed by responses to 60 photographs of faces depicting the six basic emotions (happiness, sadness, anger, fear, surprise and disgust). ToM was assessed using the Reading the Mind in the Eyes task, which requires participants to infer mental states of others from partial facial cues. Rapid facial mimicry was assessed by recording activity in the zygomaticus major and corrugator supercilii muscle regions while participants passively viewed images of happy and angry facial expressions.

RESULTS

Relative to the control group, the opiate user group exhibited deficits in both facial emotion recognition and ToM. Moreover, only control participants exhibited typical rapid facial mimicry responses to happy facial expressions.

CONCLUSIONS

These data indicate that long-term opiate users exhibit abnormalities in three distinct areas of social-cognitive processing, pointing to the need for additional work to establish how social-cognitive functioning relates to functional outcomes in this group. Such work may ultimately inform the development of interventions aimed at improving treatment outcomes for long-term opiate users.

Prevalence and Predictors of Symptoms of Depression Among Individuals Seeking Treatment from Australian Drug and Alcohol Outpatient Clinics

This study examined the prevalence of and sociodemographic characteristics associated with elevated symptoms of depression among clients seeking alcohol or other drug (AOD) treatment. Consenting clients attending two AOD outpatient clinics answered demographics, treatment questions and the Patient Health Questionnaire to assess depressive symptoms. Counts and percentages were calculated to determine the prevalence of elevated depressive symptoms. Logistic regression was used to model the odds of having elevated depressive symptoms for client demographics. Of the 203 clients who completed the survey (87% consent rate), 55% (n = 111) demonstrated elevated depressive symptoms. Females were twice as likely to experience elevated symptoms of depression compared to males (OR 2.07; 95% CI 1.05, 4.08; P = 0.037). The high rates of elevated depressive symptoms among individuals seeking AOD treatment highlight the importance of ongoing research to provide effective treatments for this comorbidity. Routine screening and clear treatment pathways may assist with providing high quality care.

A prospective observational study of heroin users in Johannesburg, South Africa: Assessing psychiatric comorbidities and treatment outcomes

BACKGROUND

Despite the rise in heroin use in sub Saharan-Africa opioid agonist maintenance treatment (OAMT) is still not state-funded in South Africa and many other African countries. In South Africa there has been little data published on the profile of heroin users and the outcomes of treatment for those who attend public treatment services.

METHODS

300 heroin users from two state-funded rehabilitation centres in Johannesburg were studied at entry into rehabilitation and 3-months after treatment. Treatment consisted of inpatient detoxification and inpatient psychosocial rehabilitation. Structured interviews measured changes in drug use, psychopathology and criminality post rehabilitation.

RESULTS

Most (65.7%) smoked heroin in combination with cannabis while 29.7% were injecting users. Almost half the sample (49.3%) had at least one mental illness. Of the 252 (84%) participants seen at 3-month follow-up, 6.3% were abstinent of all substances (excluding tobacco), 65.5% had continued heroin use (CHU) and the balance used other substances. At follow-up there were significant decreases in heroin use (p<0.0001) and criminality (p<0.0001). There were however significant increases in alcohol use (p<0.0001), crystalmetamphetamine use (p=0.032) and the prevalence of current episode of major depression (p<0.0001). Just 11.9% received formal psychosocial treatment after leaving rehabilitation. None were on OAMT and only three participants were on psychotropic medication. None were tested for Hepatitis C during the study period and the majority (53%) did not know their HIV status.

CONCLUSION

There are significant gaps in current treatment services for heroin users in South Africa. Retention in treatment and assessment and management of psychiatric and non-psychiatric comorbidities is low. Services need to be more integrated and should also include the provision of OAMT.

Anxiety Treatment of Opioid Dependent Patients with Buprenorphine: A Randomized, Double-blind, Clinical Trial

OBJECTIVE

The objective of this study is to examine the impact of vary doses of buprenorphine on anxiety symptoms in opioid-dependent inpatients over a 7 days period, using a randomized controlled trial design.

DESIGN

Patients were randomized to three groups.

PATIENTS AND METHODS

Fourteen men who met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for both opioid use disorder and generalized anxiety disorder and were seeking for treatment.

INTERVENTION

Patients obtain dosages of 32 mg or 64 mg or 96 mg of buprenorphine as a single dose only and were treated in a psychiatric inpatient unit. Of 14 subjects; 5 (35.7%) obtained 32 mg, 4 (28.6%) obtained 64 mg, and 5 (35.7%) obtained 96 mg of buprenorphine.

MEASUREMENTS

Administering daily Hamilton Anxiety Rating Scale and interview.

RESULTS

All the patients ended the 7-day treatment time. The results showed a significant reduction in anxiety symptoms within each of the three groups (P = 0.00), but no difference in outcome between the groups (P = 0.605).

CONCLUSIONS

The outcome suggests a single high dose of buprenorphine can supply a speedy, safe, simple, and suitable means of anxiety treatment. The single high dose of buprenorphine could be a novel mechanism medication that provides a rapid and sustained improvement for generalized anxiety disorder in opioid dependent patients. Placebo-controlled trials of longer duration are needed to evaluate ability, safety, and psychological and physiological influence of extended exposure to this medication.

A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia

ISSUES

The aim of this paper was to conduct a systematic review of the prevalence of comorbid mental health conditions in people accessing treatment for substance use in Australia.

APPROACH

A systematic review identified studies meeting the following eligibility criteria: reporting original data published in English; sample presenting for substance use treatment in Australia; assessing the prevalence of mental health and substance use conditions and reporting the percentage of participants with co-occurring mental health and substance use conditions. A narrative analysis was conducted because of the heterogeneity of methods used to assess key outcome variables and small number of studies assessing particular mental health outcomes. The abstracts of 1173 records were screened, and 59 full articles were assessed for eligibility. Eighteen studies were included in the review.

KEY FINDINGS

Prevalence estimates of current mental disorders in substance use treatment clients varied (47 to 100%). Mood and anxiety disorders were particularly prevalent, with the prevalence of current depression ranging from 27 to 85% and current generalised anxiety disorder ranging from 1 to 75%.

IMPLICATIONS

The high prevalence of mood and anxiety disorders in substance use treatment settings indicates a need for clinicians to screen and assess for these disorders as part of routine clinical care, and be familiar with evidence-based management and treatment strategies.

CONCLUSION

Although further studies are required to determine the prevalence of the full range of mental health disorders in this population, these findings emphasise the high prevalence of comorbid mental disorders are among individuals accessing substance use treatment in Australia. [Kingston REF, Marel C, Mills KL. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev 2017;36:527-539].

Morbidity associated with heroin overdose presentations to an emergency department: a 10-year record linkage study

INTRODUCTION

To examine hospitalizations in a cohort of 224 patients who presented with non-fatal heroin overdose to an ED.

METHODS

A record linkage study, using the morbidity, mental health and mortality databases in the Data Linkage Unit of the Department of Health, Western Australia. The main outcome measures were hospital separations 5 years before and after entry into the cohort.

RESULTS

Before entry into the cohort, 199 (89%) patients had an admission to mental health services. These 199 had a combined total of 1367 separations, most commonly for a mental health condition, injury or poisoning. Women had more than twice the relative risk (RR) of men for all separations (RR 2.35, 95% confidence interval [CI] 1.96-2.82, P < 0.001) and for injury and poisoning separations (RR 2.04, 95% CI 1.56-2.66, P < 0.001). The highest concentrations of separations occurred within 1 year before and 1 year after entry into the cohort. There were 12 (5.4%, 95% CI 2.9-9.4%) deaths, most commonly from overdose.

CONCLUSION

Non-fatal heroin overdose ED presentations are associated with a cluster of hospitalizations around that episode, likely to be related to heroin availability. Presentation to hospital by heroin users represents an opportunity to counsel less risky behaviour.

Patient satisfaction with methadone maintenance treatment: the relevance of participation in treatment and social functioning

BACKGROUND

Patients' satisfaction with methadone maintenance treatment (MMT) is a key measure of treatment quality. The main objective of the present study is to identify independent factors that contribute significantly to satisfaction with MMT.

METHOD

Participants were a representative sample of methadone-maintained patients (n=123) from the region of La Rioja. Satisfaction with MMT was assessed with the Verona Service Satisfaction Scale for Methadone Treatment (VSSS-MT), and mental health status with the General Health Questionnaire-28 (GHQ-28). Multivariate linear- and logistic-regression analyses were performed to identify variables independently associated with satisfaction with MMT.

RESULTS

Multiple linear regression analysis revealed that the variables independently associated with VSSS-MT total score were number of hours per week that the centre dispensed methadone (β=0.193), number of patients per centre (β=0.233), perceived frequency of receiving information about methadone dose changes (β=0.246), perceived influence on these changes (β=0.194), and Social Dysfunction subscale of GHQ-28 (β=-0.179). Multivariate binary logistic regression showed that the variables independently associated with the likelihood of being satisfied with MMT were number of years of education completed (OR=0.835), number of patients per centre (OR=1.009), perceived frequency of receiving information about methadone dose changes (OR=1.571), and Social Dysfunction subscale of GHQ-28 (OR=0.748).

CONCLUSIONS

Patients from larger centres, who perceive themselves as participating to some extent in treatment decisions, and showing lower deterioration in social functioning are more likely to be satisfied with MMT.

Impact of co-occurring psychiatric disorders on retention in a methadone maintenance program: an 18-month follow-up study

We assess the influence of co-occurring psychiatric disorders on retention in 189 opioid dependent patients in a methadone maintenance treatment (MMT) and determine the incidence of psychiatric co-morbidity during an 18-month follow-up period. About 68.5 % were retained in the MMT. Neither co-occurring mental disorders (chi-square = 0.303, df = 1, p = 0.622) nor methadone doses [85 (88.9) vs. 79.2 (85) mg/day, p = 0.672] were related to retention. In the follow-up period 19 new diagnoses were made, mainly major depression and antisocial and borderline personality disorders. Co-occurring psychiatric disorders should be assessed during MMT follow-up.

Gender and comorbidity among individuals with opioid use disorders in the NESARC study

This study examines gender differences in the association of lifetime mental and substance use disorders among individuals with opioid use disorders in the United States. The sample (N=578) is from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which is a representative household survey. Bivariate analyses and logistic regression modeling were conducted. About 70% of the sample had a lifetime non-substance use Axis I disorder; women were about twice as likely as men to have either a mood or anxiety disorder. About half of the sample had a personality disorder, with women more likely to have paranoid disorder and men more likely to have antisocial personality disorder. Individuals with a lifetime mental disorder were about three times more likely than others to be dependent on other substances, independent of gender. The study demonstrated an inverse relationship between lifetime mental and other substance use disorders, with women having significantly higher odds for several of the mental disorders and men having greater odds of other substance use disorders.

Injecting drug users and the Human Immunodeficiency Virus: what do we know?

This article examines the results of 10 years of research on the relationship between injecting drug use and the Human Immunodeficiency Virus (HIV). The two main transmission modes of HIV among injecting drug users (IDU)-parenteral drug use and sexual behaviour-are examined in detail, as well as the efficacy of attempted interventions to reduce the spread of HIV among this population.

Overdose in young people using heroin: associations with mental health, prescription drug use and personal circumstances

OBJECTIVE

To identify patterns of mental health, prescription drug use and personal circumstances associated with heroin overdose in young people.

DESIGN

Linkage of data on use of Pharmaceutical Benefits Scheme (PBS) prescription drugs with data from a self-report questionnaire.

SETTING

Inner metropolitan Melbourne, Australia.

SUBJECTS

163 young people, 15-30 years, using heroin.

MAIN OUTCOME MEASURES

Personal circumstances, mental health (as measured by various scales), and PBS-listed prescription drug use.

RESULTS

Young people using heroin reported high rates of feelings of hopelessness, depression, antisocial behaviour, self-harm and diagnosed mental illness. A prior history of overdose was associated with previous mental illness, which in turn was associated with being female, having poor social support, being dissatisfied with relationships, and living alone or in temporary accommodation. While feelings of hopelessness and antisocial behaviour were strongly associated with overdose history, the number of PBS prescription drugs used had a very strong relationship with overdose, particularly benzodiazepines, other opioids, tricyclic antidepressants and tranquillisers.

CONCLUSIONS

Further research to explore causal relationships between prescription drugs and heroin overdose is warranted. Improved data linkage to PBS records for general practitioners may facilitate safer prescribing practices.

Mood disorders in opioid-dependent patients

AIMS

To assess the rate of current mood disorders in opioid-dependent outpatients.

DESIGN

Prevalence study of DSM-IV mood disorders.

SETTINGS

Private and government clinics.

PARTICIPANTS

Five hundred unpaid opioid-dependent patients who had voluntarily sought treatment.

MEASUREMENTS

The Research version of structured clinical interview for DSM-IV Axis I Disorders (SCID-I).

RESULTS

The mean age of the subjects (487 men and 13 women) was 33.4 years, ranging from 16 to 67. The majority (68.2%) had private sector job and 13.4% were unemployed. The majority (59.8%) had education at the level of primary, guidance or high school and only 3.8% were illiterate. Three hundred and thirty six (67.2%) subjects were diagnosed as having mood disorders. Of the subjects 274 (54.8%) had substance induced depression, 37 (7.4%) major depression, 14 (2.8%) dysthymia, five (1%) depression due to general medical condition, three (0.6%) cylothymia, three (0.6%) bipolar mood disorder type I. None was diagnosed as having bipolar mood disorder type II. Of the participants 319 (63.8%) reported more than 5 years use of opioid. Of the subjects only 16 (3.2%) reported no episode of abstinence and the majority 484 (96.8%) reported one or more episodes of abstinences. About 4.2% (21) reported less than 1 g/day and the majority 86.4% (432) reported between 1 and 5 g/day current use of opioid.

CONCLUSION

Due to high rates of mood disorders in opioid-dependent subjects, psychiatric services should be open and accessible to the patients, especially those who voluntarily seek help and treatment.

Substitution therapy for heroin addiction

Substitution treatment for heroin addiction, defined here as maintenance prescribing of opioid agonist drugs to opioid dependent subjects, has increased in the last decade. The recent history of substitution treatment in five countries--Canada, the U.K., Australia, Israel, and France--is reviewed. In all five countries, the critical issues around substitution treatment are similar. The first key issue concerns the balance between making treatment accessible and attractive, and minimizing diversion to the black market. The second issue concerns the role of primary health care in delivering MMT. In general, there has been increasing involvement of primary health care, with training and support for practitioners. However, there remains uncertainty and official ambivalence over whether treatment should be restricted to specialist clinics and practitioners, or available through primary care. Most importantly, underlying these issues is the problem of stigma being associated with both addiction, and with substitution treatment. The underlying problem that treatment is often at odds with community values places enormous strains on substitution treatment, and makes the treatment system vulnerable to shifting community support and abrupt, politically-driven changes in policy.

Prevalence of psychiatric disorder in a methadone maintenance population

OBJECTIVE

The objective of this study was to examine the prevalence of psychiatric disorders in a group of patients who had recently entered a methadone maintenance programme.

METHOD

A total of 62 patients were interviewed using the Composite International Diagnostic Interview (CIDI) within 6 months of commencing methadone maintenance. The CIDI was used to establish symptoms of psychiatric illness at interview and in the 12 months prior.

RESULTS

In the 12 months prior to interview, 76% of the sample fulfilled ICD-10 criteria for a psychiatric disorder other than substance-use disorder. Over half of the group interviewed fulfilled ICD-10 criteria for an affective disorder, two-thirds fulfilled criteria for an anxiety disorder and just under half fulfilled diagnostic criteria for both an affective disorder and an anxiety disorder in the 12 months prior to interview. At the time of interview, 19% fulfilled ICD-10 diagnostic criteria for a moderate or severe affective disorder. Seventy per cent of males and 89% of females interviewed had a comorbid psychiatric illness. In 71% of the group who had a comorbid psychiatric illness, the onset of psychiatric symptomatology was reported to predate the use of heroin.

CONCLUSION

The prevalence of psychiatric disorder is up to 10 times higher in the population on methadone maintenance than in the general population and is two to three times higher than that found in community surveys of those with a substance-use disorder. These results are consistent with earlier findings and have implications for service planning.

Predictors of program completion for women in residential substance abuse treatment

Although there is increasing emphasis on providing drug treatment programs for women that address their specific needs (including parenting and childcare), some women still fail to complete treatment. Because of the limited information about the barriers involved, this study examines pretreatment characteristics as predictors of program completion for 87 women who were pregnant or who entered residential treatment with their children. By using a multivariate prediction model, three significant predictors of treatment completion were identified: education level, recent arrests, and peer deviance. Women who completed program requirements were more likely to have a high school degree or equivalent, no arrests in the 6 months before admission, and friends who were less deviant. These findings support the need for specialized education and services that address social deviancy of pregnant and/or parenting women. Other predictors that approached significance and deserve further study include marital status, number of children in treatment, child welfare involvement, cocaine use, and psychological depression.

A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder

The increasing demand for treatment for cannabis dependence in Australia and internationally has led to the identification of significant gaps in knowledge of effective interventions. A randomized controlled trial of brief cognitive-behavioral interventions (CBT) for cannabis dependence was undertaken to address this issue. A total of 229 participants were assessed and randomly assigned to either a six-session CBT program (6CBT), a single-session CBT intervention (1CBT), or a delayed-treatment control (DTC) group. Participants were assisted in acquiring skills to promote cannabis cessation and maintenance of abstinence. Participants were followed-up a median of 237 days after last attendance. Participants in the treatment groups reported better treatment outcomes than the DTC group. They were more likely to report abstinence, were significantly less concerned about their control over cannabis use, and reported significantly fewer cannabis-related problems than those in the DTC group. Those in the 6CBT group also reported more significantly reduced levels of cannabis consumption than the DTC group. While the therapist variable had no effect on any outcome, a secondary analysis of the 6CBT and 1CBT groups showed that treatment compliance was significantly associated with decreased dependence and cannabis-related problems. This study supports the attractiveness and effectiveness of individual CBT interventions for cannabis use disorders and the need for multisite replication trials.

Resource allocation for epidemic control over short time horizons

We present a model for allocation of epidemic control resources among a set of interventions. We assume that the epidemic is modeled by a general compartmental epidemic model, and that interventions change one or more of the parameters that describe the epidemic. Associated with each intervention is a 'production function' that relates the amount invested in the intervention to values of parameters in the epidemic model. The goal is to maximize quality-adjusted life years gained or the number of new infections averted over a fixed time horizon, subject to a budget constraint. Unlike previous models, our model allows for interacting populations and non-linear interacting production functions and does not require a long time horizon. We show that an analytical solution to the model may be difficult or impossible to derive, even for simple cases. Therefore, we derive a method of approximating the objective functions. We use the approximations to gain insight into the optimal resource allocation for three problem instances. We also develop heuristics for solving the general resource allocation problem. We present results of numerical studies using our approximations and heuristics. Finally, we discuss implications and applications of this work.

Clinical profile of participants in a brief intervention program for cannabis use disorder

The increasing demand for cannabis dependence treatment has led to the identification of significant gaps in the knowledge of effective interventions. A randomized controlled trial of brief cognitive-behavioral interventions (CBT) for cannabis dependence was undertaken to address this issue. A total of 229 participants were assessed and allocated to either a 6-session CBT program, a single-session brief intervention, or a delayed-treatment control group. This paper demonstrates that individuals with cannabis use disorder will present for a brief intervention program. While they report similar patterns of cannabis use to nontreatment samples, they report a range of serious health and psychosocial consequences. While they appear relatively socially stable, they typically demonstrated severe cannabis dependence and significantly elevated levels of psychological distress, with the most commonly cited reason for cannabis use being stress relief. There were clinically relevant gender differences among the sample. This study provides more evidence of the demand for, and nature of issues relevant to, interventions for cannabis use disorders, and supports the need for further research into how best to assist individuals with these disorders.

HIV transmission and the cost-effectiveness of methadone maintenance

OBJECTIVES

This study determined the cost-effectiveness of expanding methadone maintenance treatment for heroin addiction, particularly its effect on the HIV epidemic.

METHODS

We developed a dynamic epidemic model to study the effects of increased methadone maintenance capacity on health care costs and survival, measured as quality-adjusted life-years (QALYs). We considered communities with HIV prevalence among injection drug users of 5% and 40%.

RESULTS

Additional methadone maintenance capacity costs $8200 per QALY gained in the high-prevalence community and $10,900 per QALY gained in the low-prevalence community. More than half of the benefits are gained by individuals who do not inject drugs. Even if the benefits realized by treated and untreated injection drug users are ignored, methadone maintenance expansion costs between $14,100 and $15,200 per QALY gained. Additional capacity remains cost-effective even if it is twice as expensive and half as effective as current methadone maintenance slots.

CONCLUSIONS

Expansion of methadone maintenance is cost-effective on the basis of commonly accepted criteria for medical interventions. Barriers to methadone maintenance deny injection drug users access to a cost-effective intervention that generates significant health benefits for the general population.

A model to explain the relationship between sexual abuse and HIV risk among women

This paper presents a model developed to advance the understanding of the relationship between sexual abuse and HIV risk among women. It is proposed that the relationship is mediated by many of the long-term sequelae of sexual abuse. The process of mediation is believed to occur through various causal pathways propelled by specific underlying mechanisms that increase the likelihood of HIV risk. The following causal pathways are proposed: (1) initiation of and/or increasing reliance on drug use as a method of coping with the sexual abuse experience, (2) problems with sexual adjustment related to sex risk taking, and (3) psychopathology (e.g. depression) which increases the likelihood of an individual participating in HIV risk behaviours. These hypothesized pathways are based on the characteristics and behaviours of individuals with histories of sexual abuse and do not take into account the influence of the individual's social environment. Increasingly, evidence suggests that understanding the social context of HIV risk is crucial to the development of preventive interventions. Therefore, a final pathway is explored which suggests that specific social network characteristics (e.g. network membership type, social support, and social isolation) influence HIV risk exposure opportunities among women with sexual abuse histories.

Psychopathology, treatment completion and 5 years outcome. A prospective study of drug abusers

Two hundred Norwegian drug abusers who consecutively applied for treatment in a Phoenix-House-type of therapeutic community, were interviewed in intake and personally followed up, on average, 5 years after (response rate 79%). The year prior to follow-up, 20% had no/light use of substances and 56% heavy abuse, including the deceased (12.4%). Personality disorders and psychopathology at application did not directly predict either substance abuse problems nor level of social functioning, but were mainly related to the risk of death. Treatment completion was positively related to the 5-year outcome of social functioning, but not to substance abuse problems. Our findings indicate the need for more systematic training in how to control the use of substances in the Phoenix House model. One should also offer a more longstanding outpatient programme of social skills training, aiming at following these clients for years.

Screening for psychopathology in the clinical practice

Different instruments are used in clinical practice to assess comorbid psychopathology in addicted individuals. This study is aimed at comparing two of those instruments. In total, 327 heroin- and methadone-addicted individuals were interviewed in three treatment settings and outside treatment. Instruments used are the Addiction Severity Index (ASI) and the Composite International Diagnostic Interview (CIDI). The former instrument results in a general measure of severity of psychopathology, while the latter results in categorical DSM-III-R diagnoses. A comparison of the results show, however, that the two types of data do not agree to a large extent. By using the DSM-III-R data as golden standard, it appeared that a part of the psychopathology cases was missed out by the ASI severity measures. The results, that are especially of interest for clinicians using the ASI, are presented for various disorders.

Sex trading and psychological distress among women recruited from the streets of Harlem

OBJECTIVES

This study examines the relationship between sex trading and psychological distress and the implications of that relationship for prevention of human immunodeficiency virus among a sample of young women recruited from the streets of Harlem.

METHODS

Interviews were conducted with 346 predominantly drug-using women, aged 18 to 29 years, of whom 176 had exchanged sex for money or drugs in the previous 30 days and were categorized as "sex traders." Psychological distress was measured by using the Brief Symptom Inventory.

RESULTS

Sex traders scored significantly higher than non-sex traders on the General Severity Index and on eight of the nine subscales of the Brief Symptom Inventory. Multivariate analysis indicated that after adjustments were made for age; ethnicity; pregnancy; recent rape; perceived risk for acquired immunodeficiency syndrome; current, regular crack use; and current, regular alcohol use, sex traders scored 0.240 units higher on the General Severity Index than non-sex traders.

CONCLUSIONS

Poor mental health and drug dependence may under-mine the motivation and ability of these sex traders to adopt safer sex behavior. Therefore, interventions need to be integrated with mental health services and drug treatment to reduce risk behavior in this population.

Prescribing drug of choice to illicit heroin users: the experience of a U.K. community drug team

Functioning across several life domains, in the first cohort of illicit heroin users to be prescribed injectable diamorphine (pharmaceutical heroin) as an adjunct to treatment within a community drugs service, was assessed in a cross-sectional study with a 6-month follow-up. Case-control matching procedures were employed to compare outcomes in this group with an oral methadone-prescribed sample, attending different clinics within the same community service and geographical locale. The Heroin Prescribed (HP) group manifested lower levels of psychopathology and showed greater retention in treatment. Although reduced, illicit heroin misuse was not eliminated; the use of other illicit substances was comparable between groups but significantly more of the HP group were using illicit cocaine. Although no differences in current physical health were apparent, the sharing of used injecting equipment was reported only in the MP group. Criminal activity appeared significantly reduced, but not eliminated, in the HP group. Implications for prescribing practice are discussed.

Background and overview of mental health and substance abuse treatment systems: meeting the needs of women who are pregnant or parenting

Women with a psychiatric disorder who also abuse alcohol or other drugs have historically encountered barriers to integrated treatment for both disorders. Substance abuse treatment services and mental illness treatment services are usually organized independently of each other and few are designed to meet the needs of pregnant and parenting women. This chapter reviews the developmental histories of treatment systems for psychiatric and substance abuse disorders; the structural barriers that impede the delivery of services to individuals with co-occurring psychiatric and substance abuse disorders; the prevalence of dual disorders; issues related to diagnosis and assessment, types of diagnoses and addictions; treatment issues specific to women who are pregnant or parenting; models of service delivery; and initiatives directed at changing treatment systems.

Development of the Leeds Dependence Questionnaire (LDQ): a questionnaire to measure alcohol and opiate dependence in the context of a treatment evaluation package

The Leeds Dependence Questionnaire (LDQ) has been developed as part of a treatment evaluation package. The LDQ is a 10-item, self completion questionnaire designed to measure dependence upon a variety of substances; it has been shown to be understood by users of alcohol and opiates. The questionnaire was designed to be sensitive to change over time and to be sensitive through the range from mild to severe dependence; the follow-up data are insufficient to demonstrate change over time, but are encouraging. It is expected that both clinicians and researchers will find it useful to have a single measure relating to substance use, but not limited by specific substances. All items are scored 0-1-2-3; there are no normative data. The procedure for establishing content validity is described and estimates of concurrent, discriminant and convergent validities are reported; these validities are thought to be satisfactory. A principal components analysis produced a single factor accounting for 64% of the variance. Cronbach's alpha was 0.94. Test-retest reliability was found to be 0.95.

Prevalence, severity and correlates of psychological morbidity among methadone maintenance clients

A sample of 222 methadone maintenance clients was tested for levels of depression, anxiety, and anti-social personality disorder. The prevalence of each type of psychopathology was high. There were large proportions of subjects exhibiting extremely severe depression, anxiety and a majority were classified as "psychiatric cases". Depression and anxiety were strongly related, but anti-social behaviour was unrelated to personal distress. Personal distress levels were predicted by benzodiazepine use, poorer social functioning and poorer health. Anti-social personality disorder was predicted by younger age, being male, poorer social functioning, and current criminality.

Prevalence, symptoms and correlates of antisocial personality disorder among methadone maintenance clients

A sample of 222 methadone maintenance (MM) clients were tested for a diagnosis of antisocial personality disorder (ASPD). The majority (60.8%) of clients qualified for a lifetime diagnosis of ASPD, 25.7% received a current diagnosis of ASPD, and a conduct disorder of childhood was diagnosed for 68.5% of subjects. The most common symptoms of ASPD among MM clients were unlawful behaviours, aggressiveness and recklessness. Lack of remorse was reported by less than a third of subjects with a lifetime diagnosis of ASPD. Subjects with a current diagnosis of ASPD had been retained in treatment as long as other clients, and were no more likely to be currently injecting or sharing injecting equipment. It is concluded that clients with ASPD can be retained in MM treatment, and can respond to MM treatment as well as other clients.