Is the bipolar spectrum the psychopathological substrate of suicidality in heroin addicts?

Prevalence of and Factors Influencing Suicide Ideation, Attempt, and Completion in Heroin Users: A Systematic Review and Meta-Analysis

BACKGROUND

Suicide is considered a fundamental problem in discussions on public and global health. Thus, the current study aimed to review the prevalence of and reasons for successful suicide attempts in heroin users.

METHODS

This study was conducted by systematically searching the electronic databases of PubMed, Scopus, Web of Science, and PsycINFO from 1960/1/1 to 2021/11/1 based on the PRISMA checklist and using MeSH keywords with no temporal or linguistic limitations. The primary and secondary impacts of suicide were identified, and all studies following an observational design (cohort, case-control, and cross-sectional studies) were included in the research. Data analysis was performed using Stata version 13. Finally, 17 studies were included in the work process for systematic review and meta-analysis.

FINDINGS

The results showed the most frequent reasons for suicide among the studied individuals were gender (being female), youngness, heroin overdose, multi-drug abuse, history of repeated suicide attempts, history of psychiatric disorder (especially depression), joblessness, homelessness, distorted family relationships, etc. Moreover, the results of synthesizing the studies revealed the prevalence of suicide attempts equaled the effect size (95% CI=0.3 [0.23-0.37]) among these individuals, and the prevalence of successful suicides approached the effect size (95% CI=0.03 [0.01-0.05]).

CONCLUSION

The results of the present study showed the high prevalence of suicidal thoughts and suicide attempts among the heroin-abusing population. Furthermore, according to the findings, the prevalence of unsuccessful suicide attempts was ten times more than that of successful ones in the target population.

Delineating the Psychic Structure of Substance Use and Addictions, from Neurobiology to Clinical Implications: Ten Years Later

The diagnosis of substance use disorder is currently based on the presence of specifically identified behavioral symptoms. In addition, other psychiatric signs and symptoms accompany addictive behavior, contributing to the full picture of patients’ psychopathologic profile. Historically, such symptoms were confined within the framework of “comorbidity”, as comorbid psychiatric disorders or personality traits. However, an alternative unitary view of the psychopathology of addiction, inclusive of related psychiatric symptoms, has been claimed, with the support of epidemiological, neurobiological, and neuropsychological evidence. In the present article, we highlight the research advancements that strengthen this unified perspective. We then give an account of our group’s definition of a specific SCL-90-based construct of the psychopathology of addiction. Lastly, we discuss the benefits that can be expected to be acquired in the evaluation and treatment of patients with a longitudinal approach including psychological/psychiatric predisposing features, addictive behavior, and psychiatric manifestations.

The Effects of Trait Emotional Intelligence on Adolescent Substance Use: Findings From a Hungarian Representative Survey

Previous research has emphasized the importance of emotions in the development of adult and adolescent substance use. There is substantial evidence for deficits in emotional processing among teenagers with substance use, but few studies have investigated the association between emotional intelligence and adolescent substance use. The aim of the present study was to examine the relationship between the use of tobacco, alcohol, and illicit drugs and level of emotional intelligence among adolescents. A representative sample of high school students participated in the study (N = 2,380). Substance use patterns were assessed using data from the European School Survey Project on Alcohol and Other Drugs (ESPAD) Survey, and emotional intelligence was assessed with the Bar-On Emotional Quotient Inventory Youth Version. Self-esteem and depressive symptomatology were also assessed to compare their effects on the frequency of substance use with the effect of emotional intelligence. Results demonstrated that greater difficulty in stress management and empathy predicted a higher frequency of tobacco, alcohol, and cannabis use. However, the level of emotional intelligence showed only a weak relationship to substance use habits. Latent profile analyses supported the hypothesis that different emotional patterns and problems underlie different types of psychoactive substances. Using a multiple linear regression model, the present study found that although emotional intelligence is not a key factor underlying substance use habits, it has an individual effect on substance use beyond depressive tendencies and self-esteem. These results can be applied to both drug prevention programs and interventions in substance abuse treatment.

Evaluation and comparison of tools for diagnosing problematic prescription opioid use among chronic pain patients

Prescription opioid medications are commonly used for the treatment of chronic pain. Assessments of problematic opioid use among pain patients are inconsistent across studies, partially due to differences between various measures. Therefore, the most appropriate measure to use is often unclear. In this study we assessed problematic opioid use in a sample of 551 individuals receiving treatment for chronic pain, using three questionnaires: the Alcohol Use Disorder and Associated Disabilities Interview Schedule - Fourth Edition (AUDADIS-IV), the Current Opioid Misuse Measure (COMM) questionnaire and Portenoy's criteria (PC). These questionnaires yielded discordant positive rates of problematic use: 52.6%, 28.7%, and 17.1%, respectively, which did not change substantially when excluding AUDADIS-IV criteria of physical symptoms of tolerance and withdrawal. Although these three questionnaires share some statistically correlated content-based congruent questions, positive response rates to them were significantly different based on construction features, including questionnaires' referred time-frame, wording of questions and response alternatives. The findings of the present study illustrate strengths and limitations of the AUDADIS-IV, COMM and PC in diagnosing problematic opioid use in a population of adults suffering from chronic pain, and highlight the importance of recognizing and addressing specific questionnaire and question-related differences when identifying problematic opioid use in this population.

People Who Inject Drugs and Have Mood Disorders-A Brief Assessment of Health Risk Behaviors

BACKGROUND

People who inject drugs have a greater risk of infectious disease and mortality than other substance abusers and nondrug users. Variation in risk behavior among people who inject drugs is likely associated with comorbid mental health disorders.

OBJECTIVES

Examine the association between a history of mood disorder and recent risk behavior among people who inject drugs.

METHODS

With baseline data from a behavioral HIV prevention clinical trial in a population of people who inject drugs, we used logistic regression models to compare the risk behaviors of people who report a past diagnosis of bipolar disorder (n = 113) or depression (n = 237) to a comparison group with no history of diagnosed mental illness (n = 446). We also assessed differences between groups before and after adjusting for demographic characteristics and current depressive symptoms.

RESULTS

While there were no differences between groups in frequency of drug use, people who inject drugs who report a history of mood disorders reported more injection risk behaviors, drug overdoses, sex exchanges, and multiple partners than those with no history of mental illness. Adjusting the comparison for demographic characteristics and current depressive symptoms had little impact on these findings. Variation in risk between depression and bipolar disorder groups was minimal. Conclusions/Importance: People who inject drugs and have mood disorders have unique and significant social, clinical, and risk reduction needs. Despite the limited validity of self-reported mental health history, simply asking about a history of mood disorder may be effective for identifying a particularly vulnerable population of people who inject drugs.

Risk factors for suicide in bipolar disorder: a systematic review

BACKGROUND

Bipolar disorder confers the highest risk of suicide among major psychological disorders. The risk factors associated with bipolar disorder and suicide exist and are relevant to clinicians and researchers.

OBJECTIVE

The aim of the present study was to conduct a systematic review of articles regarding the suicide risk factors in bipolar disorder.

METHODS

A systematic review of articles on suicide risk factors in bipolar disorder, published from January 1, 2010 to April 05, 2014, on SCOPUS and PUBMED databases was carried out. Search terms were "Suicide" (medical subject headings [MeSH]), "Risk factors" (MeSH), and "Bipolar" (keyword). Of the 220 retrieved studies, 42 met the eligibility criteria.

RESULTS

Bipolar disorder is associated with an increased rate death by suicide which contributes to overall mortality rates. Studies covered a wide range of aspects regarding suicide risk factors in bipolar disorder, such as risk factors associated to Sociodemographic conditions, Biological characteristics, Drugs Relationships, Psychological Factors, Genetic Compound, Religious and Spirituals conditions. Recent scientific literature regarding the suicide risk factors in bipolar disorder converge to, directly or indirectly, highlight the negative impacts of risk factors to the affected population quality of life.

CONCLUSION

This review demonstrated that Bipolar disorders commonly leads to other psychiatric disorders and co-morbidities involving risk of suicide. Thus the risk factors are relevant to have a better diagnosis and prognosis of BD cases involving risk of suicide.

Six-month outcome in bipolar spectrum alcoholics treated with acamprosate after detoxification: a retrospective study

Background: Glutamate system is modified by ethanol and contributes both to the euphoric and the dysphoric consequences of intoxication, but there is now growing evidence that the glutamatergic system also plays a central role in the neurobiology and treatment of mood disorders, including major depressive disorders and bipolar disorders. We speculate that, using acamprosate, patients with bipolar depression (BIP-A) can take advantage of the anti-glutamate effect of acamprosate to “survive” in treatment longer than peers suffering from non-bipolar depression (NBIP-A) after detoxification. Method: We retrospectively evaluated the efficacy of a long-term (six-month) acamprosate treatment, after alcohol detoxification, in 41 patients (19 males and 22 females), who could be classified as depressed alcoholics, while taking into account the presence/absence of bipolarity. Results: During the period of observation most NBIP-A patients relapsed, whereas a majority of BIP-A patients were still in treatment at the end of their period of observation. The cumulative proportion of ‘surviving’ patients was significantly higher in BIP-A patients, but this finding was not related to gender or to other demographic or clinically investigated characteristics. The treatment time effect was significant in both subgroups. The treatment time-group effect was significant (and significantly better) for bipolar patients on account of changes in the severity of their illness. Limitations: Retrospective methodology and the lack of DSM criteria in diagnosing bipolarity. Conclusions: Bipolarity seems to be correlated with the efficacy of acamprosate treatment in inducing patients to refrain from alcohol use after detoxification (while avoiding relapses) in depressed alcoholics. Placebo-controlled clinical trials are now warranted to check the validity of this hypothesis.

Predictors of High Level of Hostility among Homeless Men on Parole

High levels of hostility present a formidable challenge among homeless ex-offenders. This cross-sectional study assessed correlates of high levels of hostility using baseline data collected on recently-released male parolees (N=472; age 18-60) participating in a randomized trial focused on prevention of illicit drug use and recidivism. Predictors of high levels of hostility included greater depressive symptomatology, lower self-esteem, having a mother who was treated for alcohol/drugs, belonging to a gang, more tangible support, having used methamphetamine and having a history of cognitive difficulties. These findings highlight the need to understand predictors of hostility among recently released homeless men and how these predictors may relate to recidivism. Research implications are discussed as these findings will shape future nurse-led harm reduction and community-based interventions.

The long-term outcomes of heroin dependent-treatment-resistant patients with bipolar 1 comorbidity after admission to enhanced methadone maintenance

OBJECTIVE

The aim of this study was to compare the long-term outcomes of treatment-resistant bipolar 1 heroin addicts with peers who were without DSM-IV axis I psychiatric comorbidity (dual diagnosis).

METHOD

104 Heroin-dependent patients (TRHD), who also met criteria for treatment resistance - 41 of them with DSM-IV-R criteria for Bipolar 1 Disorder (BIP1-TRHD) and 63 without DSM-IV-R axis I psychiatric comorbidity (NDD-TRHD) - were monitored prospectively (3 years on average, min. 0.5, max. 8) along a Methadone Maintenance Treatment Programme (MMTP).

RESULTS

The rates for survival-in-treatment were 44% for NDD-TRHD patients and 58% for BIP1-TRHD patients (p=0.062). After 3 years of treatment such rates tended to become progressively more stable. BIP1-TRHD patients showed better outcome results than NDD-TRHD patients regarding CGI severity (p<0.001) and DSM-IV GAF (p<0.001). No differences were found regarding urinalyses for morphine between groups during the observational period. Bipolar 1 patients needed a higher methadone dosage in the stabilization phase, but this difference was not statistically significant.

LIMITATIONS

The observational nature of the protocol, the impossibility of evaluating a follow-up in the case of the patients who dropped out, and the multiple interference caused by interindividual variability, the clinical setting and the temporary use of adjunctive medications.

CONCLUSIONS

Contrary to expectations, treatment-resistant patients with bipolar 1 disorder psychiatric comorbidity showed a better long-term outcome than treatment-resistant patients without psychiatric comorbidity.

Correlations between awareness of illness (insight) and history of addiction in heroin-addicted patients

In a group of 1066 heroin addicts, who were seeking treatment for opioid agonist treatment, we looked for differences in historical, demographic, and clinical characteristics, between patients with different levels of awareness of illness (insight). The results showed that, in the cohort studied, a majority of subjects lacked insight into their heroin-use behavior. Compared with the impaired-insight group, those who possessed insight into their illness showed significantly greater awareness of past social, somatic, and psychopathological impairments, and had a greater number of past treatment-seeking events for heroin addiction. In contrast with other psychiatric illnesses, the presence of awareness appears to be related to the passing of time and to the worsening of the illness. Methodologies to improve the insight of patients should, therefore, be targeted more directly on patients early in their history of heroin dependence, because the risk of lack of insight is greatest during this period.

Dynamic risk factors in the misuse of opioid analgesics

OBJECTIVE

Identify the risk factors for prescription opioid misuse among patients taking prescription opioids to deal with chronic pain.

METHODS

We examined the literature for a variety of dynamic risk factors associated with opioid misuse among the chronic pain population in order to present a narrative review. Considered were: taking single or multiple opioids, pain intensity, mental health disorders, including a history of preadolescent sexual abuse, personal and familial history of substance abuse, a history of legal problems, being a crime victim, drug-seeking behaviors, drug craving, and age.

RESULTS

A variety of risk factors have been studied in the literature. Risk factors in chronic opioid therapy patients are dynamic in that they can change with disease progression, tolerance, changes in pain quality, mental health, comorbidities, other drug therapies or drug interactions, and changes in the patient's lifestyle.

CONCLUSION

Opioid analgesic therapy must be tailored to carefully monitor all patients in order to minimize misuse and abuse, since the risk is constant and dynamic and therefore every patient is at some degree of risk for opioid misuse.

Are "social drugs" (tobacco, coffee and chocolate) related to the bipolar spectrum?

BACKGROUND

Across all ages and cultures, mankind has always used substances in order to induce pleasurable sensations or desirable psychophysical states. These substances, notably caffeine, tobacco, alcohol and chocolate, can be labeled 'social drugs'.

METHODS

We analyzed the social drug habits of 562 patients suffering from mood disorders, according to DSM-IV-R criteria (major depressive episode, recurrent depression, bipolar type I and II disorders and depression not otherwise specified). The sample was also divided into bipolar and non-bipolar according to Hypomania Check-list 32 (HCL-32), which proposes a broader concept of hypomania and soft bipolarity, comprising the spectrum of bipolar disorders proper, along with other, "softer" expressions of bipolarity intermediate between bipolar disorder and normality.

RESULTS

Using HCL-32 criteria, but DSM-IV-R criteria, a link was confirmed between bipolar spectrum and substance use including social drugs such as tobacco and coffee.

LIMITATION

Observational correlational study.

CONCLUSION

This study is in support of earlier theoretical formulations within the framework of the Pisa-San Diego collaboration.

Emotional intelligence and addictions: a systematic review

Since the millennium, an expanding number of research articles have examined the relationship between emotional intelligence (EI) and physical and mental health. The relationship between EI and addictive disorders has, however, remained relatively well-hidden. We therefore systematically reviewed and critically evaluated the literature on this relationship. We identified 51 articles on the topic of which 36 fulfilled our inclusion criteria. Results indicate that a lower level of EI is associated with more intensive smoking, alcohol use, and illicit drug use and two components of EI play a key role in addictions: "decoding and differentiation of emotions" and "regulation of emotions."

Subtyping patients with heroin addiction at treatment entry: factor derived from the Self-Report Symptom Inventory (SCL-90)

BACKGROUND

Addiction is a relapsing chronic condition in which psychiatric phenomena play a crucial role. Psychopathological symptoms in patients with heroin addiction are generally considered to be part of the drug addict's personality, or else to be related to the presence of psychiatric comorbidity, raising doubts about whether patients with long-term abuse of opioids actually possess specific psychopathological dimensions.

METHODS

Using the Self-Report Symptom Inventory (SCL-90), we studied the psychopathological dimensions of 1,055 patients with heroin addiction (884 males and 171 females) aged between 16 and 59 years at the beginning of treatment, and their relationship to age, sex and duration of dependence.

RESULTS

A total of 150 (14.2%) patients with heroin addiction showed depressive symptomatology characterised by feelings of worthlessness and being trapped or caught; 257 (24.4%) had somatisation symptoms, 205 (19.4%) interpersonal sensitivity and psychotic symptoms, 235 (22.3%) panic symptomatology, 208 (19.7%) violence and self-aggression. These dimensions were not correlated with sex or duration of dependence. Younger patients with heroin addiction were characterised by higher scores for violence-suicide, sensitivity and panic anxiety symptomatology. Older patients with heroin addiction showed higher scores for somatisation and worthlessness-being trapped symptomatology.

CONCLUSIONS

This study supports the hypothesis that mood, anxiety and impulse-control dysregulation are the core of the clinical phenomenology of addiction and should be incorporated into its nosology.

Temperament and character personality profile in relation to suicidal ideation and suicide attempts in major depressed patients

To prevent suicidal behaviour, it is important to better understand those personality traits associated with suicidal ideation and suicide attempts. A sample of 394 consecutive major depressed outpatients admitted to Bonn University Hospital was subdivided into three groups: Lifetime suicide attempters (N=32; 8.1%), suicide ideators (N=133) and patients without suicide ideation (N=229). Psychodiagnostic measures embraced the Temperament and Character Inventory (TCI), the Symptom Checklist-90-R and the Hamilton Depression Rating Scale. Suicide attempters and ideators showed higher scores on emotional distress and depression. Analysis of covariance (covariates: age, gender, depression) revealed that suicide attempters score higher on the temperament dimension harm avoidance compared with non-attempters. Suicide ideators could be distinguished from non-ideators by character dimensions in terms of lower self-directedness and higher self-transcendence. Our findings suggest that high harm avoidance is a personality trait associated with suicide attempt in major depression, whereas low self-directedness and high self-transcendence are related to suicidal ideation. As temperament dimensions represent the "emotional core" and character dimensions the "cognitive core" of personality, we discuss whether Cloninger's psychobiological model might be helpful to distinguish between non-suicide ideators, patients who do think about suicide, and patients initiating suicidal behaviour.

Affective temperaments in heroin addiction

BACKGROUND

Much of the literature has described personality disorder constructs for heroin addicts. Building on previous work we examine the relevance of affective temperament measures in these patients.

METHODS

59 consecutive stabilized methadone treated heroin addicts, 34 with and 25 without psychiatric comorbidity, were compared, regarding affective temperaments, according to the Akiskal and Mallya formulation, with 58 healthy volunteers sharing similar social and regional demographics.

RESULTS

No differences were observed between heroin addicts and controls on either depressive or hyperthymic scales. Significant discrepancies were noted in cyclothymic and irritability scales, on which heroin addicts scored higher, regardless of the presence or absence of a dual diagnosis. In a multivariate discriminant analysis, mainly cyclothymic, and (to a lesser extent) irritable traits show a distinction between heroin addicts and controls, but not between heroin addicts with and without dual diagnoses.

LIMITATION

Cross-sectional study.

CONCLUSION

Our data suggest a new hypothesis. Cyclothymic, and to a lesser extent irritable traits (the "dark side"), could represent the temperamental profile of heroin addicts, largely irrespective of comorbidity, and tend to cohere with previous conceptualizations hypothesizing "sensation-seeking" (and "novelty-seeking") as the main personality characteristics of addiction.