1072 BARRIERS AND MOTIVATORS TO UNDERTAKING PHYSICAL ACTIVITY IN ADULTS ≥ 70—A SYSTEMATIC REVIEW OF THE QUANTITATIVE LITERATURE

Background

Physical activity (PA) has multiple important benefits for older adults, but many do not undertake the recommended amount. This systematic review examined the quantitative literature detailing barriers and motivators to PA in older adults: a concurrent qualitative review is underway. Previous reviews investigated younger age groups or specific diseases.

Method

We included adults ≥70 years, observational studies and baseline data for randomised controlled trials (RCTs); we excluded studies of specific disease groups, care home residents, and rates of cognitive impairment above population norms. We searched Medline, Embase, CINAHL and PsycINFO on 25th February 2020. We assessed risk-of-bias using ROBANS. We undertook a narrative review; meta-analysis was not possible. The protocol was registered on PROSPERO (CRD42021160503).

Results

We identified 35 papers (24 cross-sectional studies, eight prospective cohort studies, two studies of baseline data from RCTs and one mixed method study); n = 26,264 subjects, median age 77.7 years (range 70–101) and median percentage female 62.1% (range 0–100). Quality assessment identified low risk-of-bias overall, except two studies were identified as having a high risk-of-bias for one section (confounding variables). The most cited barriers were physical health (N = 14 studies), environmental factors (N = 12), fear of falls (N = 7) and lack of interest (N = 4). Other barriers identified were lack of company (N = 1) and urine leakage (in women) (N = 1). Key motivating factors included social aspects of PA (N = 8), intrinsic/psychological (e.g. self-determination, future orientation) (N = 8), health (e.g. doctor’s advice) (N = 7) and environmental (e.g. nearby green space) (N = 4).

Discussion

This review identified key barriers and motivators to PA in older adults. There is a lack of evidence for the oldest old. These findings should be used to create trials of suitable interventions which enable older adults to take up and maintain recommended levels of PA. The wide range of factors we identified indicates an individualised approach may be best.

Long-term excess mortality associated with diabetes following acute myocardial infarction: a population-based cohort study

BACKGROUND

The long-term excess risk of death associated with diabetes following acute myocardial infarction is unknown. We determined the excess risk of death associated with diabetes among patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) after adjustment for comorbidity, risk factors and cardiovascular treatments.

METHODS

Nationwide population-based cohort (STEMI n=281 259 and NSTEMI n=422 661) using data from the UK acute myocardial infarction registry, MINAP, between 1 January 2003 and 30 June 2013. Age, sex, calendar year and country-specific mortality rates for the populace of England and Wales (n=56.9 million) were matched to cases of STEMI and NSTEMI. Flexible parametric survival models were used to calculate excess mortality rate ratios (EMRR) after multivariable adjustment. This study is registered at ClinicalTrials.gov (NCT02591576).

RESULTS

Over 1.94 million person-years follow-up including 120 568 (17.1%) patients with diabetes, there were 187 875 (26.7%) deaths. Overall, unadjusted (all cause) mortality was higher among patients with than without diabetes (35.8% vs 25.3%). After adjustment for age, sex and year of acute myocardial infarction, diabetes was associated with a 72% and 67% excess risk of death following STEMI (EMRR 1.72, 95% CI 1.66 to 1.79) and NSTEMI (1.67, 1.63 to 1.71). Diabetes remained significantly associated with substantial excess mortality despite cumulative adjustment for comorbidity (EMRR 1.52, 95% CI 1.46 to 1.58 vs 1.45, 1.42 to 1.49), risk factors (1.50, 1.44 to 1.57 vs 1.33, 1.30 to 1.36) and cardiovascular treatments (1.56, 1.49 to 1.63 vs 1.39, 1.36 to 1.43).

CONCLUSIONS

At index acute myocardial infarction, diabetes was common and associated with significant long-term excess mortality, over and above the effects of comorbidities, risk factors and cardiovascular treatments.

Determinants of excess mortality following unprotected left main stem percutaneous coronary intervention

OBJECTIVE

For percutaneous coronary intervention (PCI) to the unprotected left main stem (UPLMS), there are limited long-term outcome data. We evaluated 5-year survival for UPLMS PCI cases taking into account background population mortality.

METHODS

A population-based registry of 10 682 cases of chronic stable angina (CSA), non-ST-segment elevation acute coronary syndrome (NSTEACS), ST-segment elevation myocardial infarction with (STEMI+CS) and without cardiogenic shock (STEMI-CS) who received UPLMS PCI from 2005 to 2014 were matched by age, sex, year of procedure and country to death data for the UK populace of 56.6 million people. Relative survival and excess mortality were estimated.

RESULTS

Over 26 105 person-years follow-up, crude 5-year relative survival was 93.8% for CSA, 73.1% for NSTEACS, 77.5% for STEMI-CS and 28.5% for STEMI+CS. The strongest predictor of excess mortality among CSA was renal failure (EMRR 6.73, 95% CI 4.06 to 11.15), and for NSTEACS and STEMI-CS was preprocedural ventilation (6.25, 5.05 to 7.75 and 6.92, 4.25 to 11.26, respectively). For STEMI+CS, the strongest predictor of excess mortality was preprocedural thrombolysis in myocardial infarction (TIMI) 0 flow (2.78, 1.87 to 4.13), whereas multivessel PCI was associated with improved survival (0.74, 0.61 to 0.90).

CONCLUSIONS

Long-term survival following UPLMS PCI for CSA was high, approached that of the background populace and was significantly predicted by co-morbidity. For NSTEACS and STEMI-CS, the requirement for preprocedural ventilation was the strongest determinant of excess mortality. By contrast, among STEMI+CS, in whom survival was poor, the strongest determinant was preprocedural TIMI flow. Future cardiovascular cohort studies of long-term mortality should consider the impact of non-cardiovascular deaths.

The impact of eliminating age inequalities in stage at diagnosis on breast cancer survival for older women

BACKGROUND

Older women with breast cancer have poorer relative survival outcomes, but whether achieving earlier stage at diagnosis would translate to substantial reductions in mortality is uncertain.

METHODS

We analysed data on East of England women with breast cancer (2006-2010) aged 70+ years. We estimated survival for different stage-deprivation-age group strata using both the observed and a hypothetical stage distribution (assuming that all women aged 75+ years acquired the stage distribution of those aged 70-74 years). We subsequently estimated deaths that could be postponed beyond 5 years from diagnosis if women aged 75+ years had the hypothetical stage distribution. We projected findings to the English population using appropriate age and socioeconomic group weights.

RESULTS

For a typically sized annual cohort in the East of England, 27 deaths in women with breast cancer aged 75+ years can be postponed within 5 years from diagnosis if their stage distribution matched that of the women aged 70-74 years (4.8% of all 566 deaths within 5 years post diagnosis in this population). Under assumptions, we estimate that the respective number for England would be 280 deaths (5.0% of all deaths within 5 years post diagnosis in this population).

CONCLUSIONS

The findings support ongoing development of targeted campaigns aimed at encouraging prompt presentation in older women.

Estimating the potential survival gains by eliminating socioeconomic and sex inequalities in stage at diagnosis of melanoma

BACKGROUND

Although inequalities in cancer survival are thought to reflect inequalities in stage at diagnosis, little evidence exists about the size of potential survival gains from eliminating inequalities in stage at diagnosis.

METHODS

We used data on patients diagnosed with malignant melanoma in the East of England (2006-2010) to estimate the number of deaths that could be postponed by completely eliminating socioeconomic and sex differences in stage at diagnosis after fitting a flexible parametric excess mortality model.

RESULTS

Stage was a strong predictor of survival. There were pronounced socioeconomic and sex inequalities in the proportion of patients diagnosed at stages III-IV (12 and 8% for least deprived men and women and 25 and 18% for most deprived men and women, respectively). For an annual cohort of 1025 incident cases in the East of England, eliminating sex and deprivation differences in stage at diagnosis would postpone approximately 24 deaths to beyond 5 years from diagnosis. Using appropriate weighting, the equivalent estimate for England would be around 215 deaths, representing 11% of all deaths observed within 5 years from diagnosis in this population.

CONCLUSIONS

Reducing socioeconomic and sex inequalities in stage at diagnosis would result in substantial reductions in deaths within 5 years of a melanoma diagnosis.

How much of the deprivation gap in cancer survival can be explained by variation in stage at diagnosis: an example from breast cancer in the East of England

Socioeconomic differences in cancer patient survival exist in many countries and across cancer sites. In our article, we estimated the number of deaths in women with breast cancer that could be avoided within 5 years from diagnosis if it were possible to eliminate socioeconomic differences in stage at diagnosis. We analysed data on East of England women with breast cancer (2006-2010). We estimated survival for different stage-age-deprivation strata using both the observed and a hypothetical stage distribution (assuming all women acquired the stage distribution of the most affluent women). Data were analysed on 20,738 women with complete stage information (92%). Affluent women were less likely to be diagnosed in advanced stage. Relative survival decreased with increasing level of deprivation. Eliminating differences in stage at diagnosis could be expected to nearly eliminate differences in relative survival for women in deprivation groups 3 and 4, but would only approximately halve the difference in relative survival for women in the most deprived group (5). This means, for a typical cohort of women diagnosed in a calendar year with breast cancer, eliminating deprivation differences in stage at diagnosis would prevent ∼40 deaths in the East of England from occurring within 5 years from diagnosis. Using appropriate weighting we estimated the respective number of avoidable deaths for the whole of England to be ∼450. The findings suggest that policies aimed at reducing inequalities in stage at diagnosis between women with breast cancer are important to reduce inequalities in breast cancer survival.

A comprehensive assessment of the impact of errors in the cancer registration process on 1- and 5-year relative survival estimates

Background:

When making international comparisons of cancer survival, it is essential reported differences are real effects and not an artefact of potential errors in cancer registration.

Methods:

We use simulation methods to assess the impact of various cancer registration errors on commonly reported outcomes of cancer survival (1-, and 5-year relative survival estimates). We draw two samples of patients diagnosed with cancer from one population and introduce potential registration errors in one of the sample populations under various assumptions. We investigate the effect of errors individually as well as the composite effect when combined with other registration errors.

Results:

The results indicate that high levels of cancer registration errors are necessary to make a noticeable effect on commonly reported metrics of cancer survival. Differences of up to 3 percentage units in the 5-year relative survival proportion are seen under plausible scenarios.

Conclusion:

This study is a comprehensive assessment of cancer registration errors and the consequent impact on commonly reported survival statistics. We show that under plausible scenarios, it is very unlikely that these biases are large enough to explain the variation in international comparisons of cancer survival. Registration errors will also impact on other metrics reported from registry data, such as incidence.

Should relative survival be used with lung cancer data?

BACKGROUND

Under certain assumptions, relative survival is a measure of net survival based on estimating the excess mortality in a study population when compared with the general population. Background mortality estimates are usually taken from national life tables that are broken down by age, sex and calendar year. A fundamental assumption of relative survival methods is that if a patient did not have the disease of interest then their probability of survival would be comparable to that of the general population. It is argued, as most lung cancer patients are smokers and therefore carry a higher risk of smoking-related mortalities, that they are not comparable to a population where the majority are likely to be non-smokers.

METHODS

We use data from the Finnish Cancer Registry to assess the impact that the non-comparability assumption has on the estimates of relative survival through the use of a sensitivity analysis.

RESULTS

Under realistic estimates of increased all-cause mortality for smokers compared with non-smokers, the bias in the estimates of relative survival caused by the non-comparability assumption is negligible.

CONCLUSION

Although the assumption of comparability underlying the relative survival method may not be reasonable, it does not have a concerning impact on the estimates of relative survival, as most lung cancer patients die within the first 2 years following diagnosis. This should serve to reassure critics of the use of relative survival when applied to lung cancer data.

The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients

The authors examined the relationship of comorbid non-substance use psychiatric disorders to preadmission problem status and treatment outcomes in 278 methadone maintenance patients. Recent admissions were assigned DSM-III-R Axis I and II diagnoses according to structured diagnostic interviews. The Addiction Severity Index was administered at admission to assess past and current substance use and psychosocial problems and again 7 months later. Treatment retention and month 7 drug urinalysis results were also obtained. Across substance use and psychosocial domains, participants showed significant and comparable levels of improvement regardless of comorbidity. Comorbid participants received more concurrent psychiatric treatment which may have accounted for the lack of differential improvement among groups. Nevertheless, psychiatric comorbidity was associated with poorer psychosocial and medical status at admission and follow-up and participants with the combination of Axis I and II comorbidity had the most severe problems. Admission and month 7 substance use were, for the most part, not related to psychiatric comorbidity, although there was a trend indicating more treatment attrition for participants with personality disorders.

The effectiveness of two intensities of psychosocial treatment for cocaine dependence

Structured treatments for cocaine dependence have been shown to be effective despite high attrition rates. What is unclear is what level of treatment intensity is needed to improve and sustain patient outcomes, especially among low SES urban residents. This study evaluated whether there were differences between two levels of treatment intensities for cocaine dependence in reducing substance use and improving health and social indicators. Ninety-four cocaine dependent predominantly African-American male veterans were randomly assigned to either a 12 h/week day hospital program (DH12) or a 6 h/week outpatient program (OP6) and were evaluated at baseline, during treatment and at 4 and 7 months post-treatment. Both treatments stressed abstinence, behavior change and prosocial adjustment and only differed in level of treatment intensity. During treatment measures included urine toxicologies, program attendance, treatment completion and aftercare attendance. Participants reported a 52% reduction in days of cocaine use and experienced significant improvements in employment and psychiatric functioning at seven months post-treatment. However, there was no significant difference between the DH12 and OP6 programs in terms of abstinence during treatment, treatment completion, treatment or aftercare attendance or any Addiction Severity Index (ASI)-related variable assessing level of functioning at 4 and 7 months. While future research with a larger community-based sample that includes female clients is necessary, the current findings demonstrate that a 6 h/week program is just as effective and thus has a significant cost savings compared to a 12 h/week treatment modality for cocaine dependence.

Generalizability of the clinical dimensions of the Addiction Severity Index to nonopioid-dependent patients

Clinical dimensions (CDs) for the Addiction Severity Index recently have been established for application among opioid-dependent patients in methadone treatment (P. A. McDermott et al., 1996). This article examines the generalizability of the CDs to other substance-dependent patients. A sample of 2,027 adult nonopioid-dependent patients was identified; it comprised 581 primarily cocaine-dependent, 544 primarily alcohol-dependent, and 803 polydrug-dependent patients and 99 patients who were dependent on other varied drugs. Generality of dimensions was assessed through confirmatory components analysis, structural congruence, internal consistency, and variance partitioning in higher order factoring. The CDs were found generalizable overall and to specific nonopioid-dependent subgroups, and across patient gender and age, and to African American and White patients. Preliminary concurrent and predictive validity data supported the CD structure.

Generalizability of the clinical dimensions of the Addiction Severity Index to nonopioid-dependent patients

Clinical dimensions (CDs) for the Addiction Severity Index recently have been established for application among opioid-dependent patients in methadone treatment (P. A. McDermott et al., 1996). This article examines the generalizability of the CDs to other substance-dependent patients. A sample of 2,027 adult nonopioid-dependent patients was identified; it comprised 581 primarily cocaine-dependent, 544 primarily alcohol-dependent, and 803 polydrug-dependent patients and 99 patients who were dependent on other varied drugs. Generality of dimensions was assessed through confirmatory components analysis, structural congruence, internal consistency, and variance partitioning in higher order factoring. The CDs were found generalizable overall and to specific nonopioid-dependent subgroups, and across patient gender and age, and to African American and White patients. Preliminary concurrent and predictive validity data supported the CD structure.

Contrasts between admitters and deniers of drug use

This study evaluated the agreement between self-reported drug use and urinalysis results in 232 men and 27 women opiate-dependent patients at 2, 7, and 24 months following admission to methadone maintenance treatment. Differences between deniers, those who stated that they had not used drugs, but whose urinalysis results were positive, and admitters of drug use on several psychosocial variables, Axis I and II pathology and degree of psychopathy were examined. Generally, more drug use was acknowledged by self-report than found in urinalyses. Evidence was limited that deniers were consistently different than admitters. Deniers had a significantly greater increase from initial psychopathy ratings made using interview only information to final psychopathy ratings made utilizing interview and collateral information.

Baseline prediction of 7-month cocaine abstinence for cocaine dependence patients

A broad range of baseline subject variables was evaluated to identify predictors of 7-month cocaine use for 160 lower socioeconomic cocaine dependent male veteran patients participating in either an intensive 1-month day hospital (DH; n=90) or a 1-month inpatient (INP; n=70) treatment program. The baseline measures included sociodemographic variables, the seven Addiction Severity Index composite scores, cocaine urine toxicology, craving, the SCL-90 total score, and lifetime psychiatric diagnoses. Since a proportion of subjects who reported no use at follow-up had positive urines, both liberal and conservative data estimation strategies were employed for subjects without urine toxicology data at follow-up who had reported no use (21% of subjects). Analyses were done separately for the DH and INP subjects. Under the conservative definition of cocaine abstinence/use, univariate correlations of predictor variables with 7-month cocaine use revealed no statistically significant relationships. Under the liberal definition of cocaine abstinence/use, only one variable, greater severity of alcohol problems at intake predicted cocaine abstinence at outcome. Because of the inability to predict treatment success, originally planned logistic regression analyses were not undertaken. The findings point to the difficulty of predicting long-term outcomes in cocaine dependent patients based on baseline information and to the importance of obtaining objective data on cocaine use.

Familial risk for alcoholism and self-reported psychopathology

Three groups of young men varying in familial alcoholism risk (high density, high risk [HDHR]; low density, high risk [LDHR]; and low risk [LR]) were compared on the 11 clinical scales of the Personality Assessment Inventory. Significant group differences were found on 9 scales, with scores of the HDHR group exceeding those of the other 2 groups. No differences were found between the LDHR and LR groups. When the proportion with pathological scores per scale was examined, significant group differences were still revealed on 7 scales. The HDHR group exceeded the other 2 groups, but the LDHR group also exceeded the LR group on several scales. These findings support the need to more finely characterize familial alcoholism risk than is provided by the typical high-risk-low-risk dichotomy. Finally, statistically controlling for normal variations in response style reduced the number of group differences, although the same patterns persisted.

Generality of Psychopathy Checklist-Revised factors over prisoners and substance-dependent patients

The Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991) is an often-used device for assessment of adult antisociality. This research examined generalizability by replicating the 2-factor model for a sample of 326 male prisoners and assessing its congruence and relative reliability and specificity among 620 substance-dependent patients. Generality was assessed also across addiction subtypes (opioid, cocaine, and alcohol), age, gender, and ethnicity. The 2-factor model was found inappropriate for the substance-dependent samples, whereas a unidimensional model represented by the PCL-R total score was found generalizable across prison and substance-dependent samples.

Skin pH changes associated with iontophoresis

STUDY DESIGN

Randomized controlled trial. The researcher measuring skin pH was blinded to group assignment.

OBJECTIVES

To compare the skin surface pH changes associated with iontophoresis. The investigation was designed to address the question of whether significant skin pH changes occur under the cathode on the skin surface when performing iontophoresis and assessed the influence of different electrode-buffering systems intended to stabilize skin pH (surface).

BACKGROUND

Whether buffers are needed to stabilize skin pH during iontophoresis has not been thoroughly addressed in the literature. The effectiveness of immobile resins versus simple phosphate buffers is also unclear.

METHODS AND MEASURES

Sixty volunteer subjects were administered iontophoresis of normal saline using buffered or nonbuffered electrode systems. Each subject participated in 1 of the 12 doses by electrode conditions (i.e., 5 subjects per group). Surface skin pH was measured before and after iontophoresis with a flat-surface pH electrode in concert with an analog pH meter. The independent variables were electrode type (4 levels) and dosage (3 levels). The dependent variable was the change in skin surface pH.

RESULTS

A significant change in skin pH was found only when the treatment dose was 80 mA/minute with a nonbuffered electrode (x = 3.14 +/- 1.09).

CONCLUSIONS

The skin pH changes that occur during a properly delivered iontophoresis treatment at dosages of 20 and 40 mA/min were small and not significantly different with or without the addition of buffers. Those pH changes associated with 80 mA/min doses were significantly greater when no buffer was employed but were stabilized by each of the buffers used in the study (preloaded immobile resins or simple phosphates added at point of treatment).

Comparability of telephone and In-person structured clinical interview for DSM-III-R (SCID) diagnoses

The SCID was administered twice, once by telephone and once in person (1 week later) to 41 college age men. For major depression (lifetime k =.64, current k =.66), results indicated good agreement. The lifetime occurrence estimate based on the telephone SCID diagnosis was lower than the in-person SCID estimate. Kappas for specific diagnoses were calculable for simple phobia (lifetime k =. 47, current k = .03) and social phobia (lifetime k =.29). Base rates were less than 10% for all individual diagnoses except lifetime major depression; therefore, the kappas may be unstable. For all diagnoses where there were any positive cases, percentages of negative agreement and specificity were high, whereas percentages of positive agreement and sensitivity were lower. Overall agreement was fair for specific lifetime diagnoses but poor for current diagnoses. These results suggest caution in assuming comparability of in-person and telephone SCID diagnoses. Circumstances under which a telephone SCID may be useful and ways to improve reliability are discussed.

Antisocial personality disorder and psychopathy in cocaine-dependent women

OBJECTIVE

The goal of this study was to examine the lifetime prevalence of antisocial personality disorder according to five diagnostic systems and the prevalence of psychopathy in a study group of women. The relationship between antisocial personality disorder and psychopathy was also examined. Finally, differences in treatment admission variables based on the presence or absence of antisocial personality disorder and/or psychopathy were evaluated.

METHOD

Antisocial personality disorder was diagnosed in 137 treatment-seeking, cocaine-dependent women according to the Feighner criteria, Research Diagnostic Criteria (RDC), and DSM-III, DSM-III-R, and DSM-IV criteria. Psychopathy was assessed by the Revised Psychopathy Checklist.

RESULTS

Rates of antisocial personality disorder varied from 76% according to the Feighner criteria to 11% for the RDC. Nineteen percent (N = 26) of the women scored in the moderate to high range on the Revised Psychopathy Checklist. All of these women were diagnosed with antisocial personality disorder according to DSM-III and Feighner criteria, but only 15 of the 26 were diagnosed according to DSM-III-R, 12 according to DSM-IV, and six with the RDC. Moderate levels of psychopathy were associated with a history of illegal activity at treatment admission, whereas antisocial personality disorder was not.

CONCLUSIONS

There was relatively little diagnostic agreement between classification systems. This study indicates that antisocial personality disorder and psychopathy are not synonymous terms for the same disorder. Findings support a need to redefine antisocial personality disorder diagnostic criteria to make them gender neutral by including behaviors associated specifically with antisociality in women.

The relationship of alcohol use to cocaine relapse in cocaine dependent patients in an aftercare study

OBJECTIVE

To examine the relationship between alcohol use and cocaine relapse.

METHOD

Ninety-eight cocaine-dependent male patients in aftercare were followed for 6 months following completion of an intensive outpatient rehabilitation program (IOP). Past and current alcohol dependence was assessed at entrance into aftercare, and drinking behavior prior to cocaine relapse and "near miss" episodes was assessed at 3- and 6-month follow-ups. Data on cocaine and alcohol use throughout the follow-up were also obtained.

RESULTS

Patients who had never met criteria for alcohol dependence and those with current alcohol dependence had worse cocaine outcomes (cocaine use on 10% and 7% of the days in the follow-up, respectively) than those with past alcohol dependence (cocaine use on 3% of the days in the follow-up), although alcohol dependence status no longer predicted cocaine use outcomes when cocaine use in IOP was controlled. Alcohol use in 4 of the first 5 follow-up months significantly predicted cocaine relapse status in the next month after cocaine use in IOP and alcohol dependence diagnosis at baseline were controlled. Patients who experienced cocaine relapses were much more likely to report drinking before the onset of the episode than those who had "near misses," particularly on the day of the episode (40% vs. 6% at 3 months; 62% vs. 0% at 6 months). Alcohol did not appear to be a factor in the relapses of cocaine patients with no history of alcohol dependence, even though they did report drinking on 5% of the days in the follow-up.

CONCLUSIONS

Relapse prevention efforts with cocaine abusers who have histories of alcohol dependence should include interventions designed to reduce drinking.

Long-term test-retest reliability of personality disorder diagnoses in opiate dependent patients

This investigation reports the two year test-retest reliability of DSM-III-R personality disorder (PD) diagnoses in a sample of 219 patients with opiate dependence admitted to methadone treatment. Different MA/PhD interviewers at each assessment used a semistructured diagnostic interview for PD, the Structured Interview for DSM-III-R Personality Disorders (SIDP-R), to make their diagnoses. The reliability of any PD diagnosis versus no PD was fair (kappa = .51). The reliability for any specific PD (weighted kappa = .31) was poor. Antisocial (kappa = .45) and sadistic (kappa = .42), were the only specific PDs for which at least fair reliability was achieved. At the cluster level, only Cluster B had fair reliability (kappa = .47). The intraclass correlation coefficients between number of criteria for the specific PDs at the two evaluation points were consistently higher (range .22 to .62.) than were the corresponding kappas for categorical diagnoses. In that the base rates for most of the PDs were low and agreement for the specific PDs typically exceeded 90%. Increasing the base rate by lowering the diagnostic threshold, or examining more severe cases by raising the diagnostic threshold, did not consistently effect reliability. Reasons for the low kappa coefficients and the implications for PD research are discussed.

A typology of antisociality in methadone patients

Multistage cluster analyses with replications were used to sort score profiles of 252 methadone maintained men on 4 continuous measures of antisociality--childhood conduct disorder and adult antisocial personality disorder symptoms, the revised Psychopathy Checklist, and the Socialization scale of the California Psychological Inventory. The analysis yielded 6 replicable and temporally stable cluster groups varying in degree and pattern of antisociality. The groups were statistically compared on sets of external criterion variables--Addiction Severity Index measures of past and recent substance abuse and functioning and lifetime criminal history. Axis I and II symptomatology, anxiety and depression, object relations and reality testing, hostility, guilt, and machiavellianism. The expression of antisociality in the 6 groups and differences found among them on the external variables supported the validity of a more complex conceptualization of antisociality than is provided by antisocial personality disorder.

Personality pathology and drinking in young men at high and low familial risk for alcoholism

OBJECTIVE

Three groups varying in familial alcoholism risk were compared with respect to amount of alcohol consumption, presence of personality pathology, and the relationship between personality pathology and alcohol consumption.

METHOD

Research subjects were young adult men recruited from local colleges, a trade school and the community. The risk groups included (1) a group with a biological alcoholic father and significant additional familial alcoholism (n = 106); (2) subjects with an alcoholic father, but without significant additional familial alcoholism (n = 100); and (3) a group with no paternal alcoholism and at most only one second/third-degree alcoholic relative (n = 190). Absolute daily ounces of alcohol was determined using a standard quantity-frequency scale. Prevalence of DSM-III-R personality disorders (PDs) was evaluated using the Personality Disorder Questionnaire-Revised both with and without application of an impairment and distress scale. Familial risk determination was based on agreement between four separate self-report assessments.

RESULTS

The first group consumed significantly more alcohol than the other two groups, which did not differ in alcohol consumption. The first group's subjects were more likely to meet criteria for virtually all of the PD diagnoses than were the other two groups. A greater proportion of the second group's subjects qualified for various PDs than did the third group's subjects. Personality pathology was consistently or usually associated with more drinking in the first and third groups, respectively, but associated with less consumption in the second group.

CONCLUSIONS

Young men with high-density familial alcoholism are at greater risk for the development of alcoholism than those with alcoholic fathers and little additional familial alcoholism. Relationships between personality pathology and alcohol consumption, and possibly the development of alcoholism, differ for the three risk groups.

A typology of antisociality in methadone patients

Multistage cluster analyses with replications were used to sort score profiles of 252 methadone maintained men on 4 continuous measures of antisociality--childhood conduct disorder and adult antisocial personality disorder symptoms, the revised Psychopathy Checklist, and the Socialization scale of the California Psychological Inventory. The analysis yielded 6 replicable and temporally stable cluster groups varying in degree and pattern of antisociality. The groups were statistically compared on sets of external criterion variables--Addiction Severity Index measures of past and recent substance abuse and functioning and lifetime criminal history. Axis I and II symptomatology, anxiety and depression, object relations and reality testing, hostility, guilt, and machiavellianism. The expression of antisociality in the 6 groups and differences found among them on the external variables supported the validity of a more complex conceptualization of antisociality than is provided by antisocial personality disorder.

A psychometric evaluation of the Defense Style Questionnaire in methadone patients

The self-report Defense Style Questionnaire (DSQ) was designed to assess defenses along a developmental continuum. Factor analysis of the original DSQ suggested that the scale assessed four factors or types of defenses, whereas a more recent factor analysis indicated the DSQ measured three-factors: Immature, Neurotic, and Mature. No data, however, regarding the reliability or unique construct validity of DSQ dimensions was published. This article reports on factor analyses of two DSQ versions in a sample of 215 methadone maintenance patients. Results indicate that both DSQ versions are unidimensional, assessing only Immature defenses. The lack of published psychometric data raises concerns regarding the true reliability of DSQ dimensions reported in previous investigations. Prior statements based on DSQ findings may have been incorrect if the DSQ factors were unreliable. Findings from this investigation stress the importance of requiring and evaluating the psychometric integrity of an instrument before employing it in research.

Gender differences in the relationship of antisocial personality disorder criteria to Psychopathy Checklist-Revised scores

The relationship among adult, child, and full antisocial personality disorder (APD) criteria with the Psychopathy Checklist-Revised (PCL-R) (Hare, 1991) scores, an alternative to the Diagnostic and Statistical Manual of Mental Disorders' APD diagnosis, is examined in 395 men and 121 women substance abusers. Based on prior research, it was hypothesized that the correlations among childhood, adult, and full APD criteria and PCL-R Total, Factor 1 (Psychopathic Personality Traits), and Factor 2 (Antisocial Lifestyle) scores would differ for men and women. There was no difference between men and women in the correlations between full APD and PCL-R scores. Adult APD, however, had a stronger relationship to the Total and Factor 1 PCR-R scores in women compared to men, whereas child APD criteria were significantly related, although weakly, to Factor 1 scores for men, but not for women.

Predictors of participation in aftercare sessions and self-help groups following completion of intensive outpatient treatment for substance abuse

OBJECTIVE

The goals of this study were to identify predictors of greater participation in aftercare treatment sessions and self-help groups during the first 3 months following completion of a 4-week intensive outpatient rehabilitation (IOP) program.

METHOD

The subjects were 138 male veterans who met DSM-III-R criteria for lifetime diagnoses of both alcohol and cocaine dependence (n = 67), alcohol dependence only (n = 48) or cocaine dependence only (n = 23); completed an IOP program; and expressed a desire to enter a formal aftercare program. Analyses examined relationships between predictor variables from five different domains and number of aftercare sessions and self-help groups attended in the last week of each month of the follow-up period.

RESULTS

Of the many potential predictor variables that were examined, only remission from cocaine and alcohol dependence during IOP and higher AIDS risk behavior scores in the prior 6 months contributed independently to the prediction of greater participation in aftercare. Further analyses identified several variables that were differential predictors of participation in individualized relapse prevention aftercare versus standard 12-step focused group aftercare. More years of cocaine use, greater current legal problems and a lack of current alcohol dependence predicted greater self-help participation at the level of a trend.

CONCLUSIONS

The achievement of remission from substance use dependence during IOP may be an important criterion for moving to the next level of care. However, the results of the present study also point to the need for an increased focus on factors present during the course of aftercare in future studies of retention in aftercare following outpatient rehabilitation.

Prediction of 7 months methadone maintenance treatment response by four measures of antisociality

Zero-order correlational and simultaneous regression analyses were performed to ascertain the comparative validity of four measures of antisociality for predicting the initial 7 months treatment response of 193 male methadone maintenance (MM) patients. Predictor variables were the number of childhood conduct disorder (CD) behaviors, number of adult antisocial personality disorder (A-APD) behaviors, the revised Psychopathy Checklist (PCL-R) score and the revised California Psychological Inventory-Socialization (CPI-So) scale score. The outcome measures were completion/noncompletion of 7 months of treatment, percent positive during-treatment of cocaine, opiate and benzodiazepine urine toxicologies, and change from baseline to 7 months follow-up in seven Addiction severity index (ASI) composite scores (CSs). All four measures of antisociality were significantly correlated with treatment noncompletion, although only the PCL-R score was significant in the predictor model. The PCL-R predicted more positive cocaine urines. At the individual level, both PCL-R and CPI-So were associated with more positive benzodiazepine urines, but neither contributed a significant amount of variance when both were entered in the model. None of the predictors were significantly associated with self reported improvement in the CSs. The PCL-R and CPI-So were more successful in predicting outcomes than the two behavior-based measures.

The early course of change in methadone maintenance

AIMS

This study examined the functional and substance use status of methadone maintenance (MM) patients at treatment entry and 2 and 7 months later.

DESIGN

Two groups of subjects were identified for longitudinal follow-up, those in continuous MM treatment and those who left treatment.

SETTING

The study was conducted at the Philadelphia Veterans Affairs Medical Center MM Program.

PARTICIPANTS

Subjects were 157 men admitted to treatment.

MEASUREMENTS

Change was evaluated using the Addiction Severity Index and urinalysis results.

FINDINGS

Both groups of subjects reported significant reductions in drug use and increases in psychosocial functioning from admission to month 2, but demonstrated no significant changes from months 2 to 7. Subjects who left treatment, however, had more heroin use and criminal activity at all evaluation points than subjects who remained in treatment. Urinalysis data also suggested that subjects who left treatment were using drugs more frequently while in treatment than were those subjects who remained continuously enrolled in MM. Finally, subjects who left treatment spent more time in restricted environments (e.g. inpatient treatment, jail) at follow-up.

CONCLUSIONS

Services may need to be enhanced to foster continuing progress in patients who remain in MM treatment and to retain those patients with more severe problems who leave treatment early.

Group counseling versus individualized relapse prevention aftercare following intensive outpatient treatment for cocaine dependence: initial results

Ninety-eight male cocaine-dependent patients who completed an intensive outpatient program (IOP) were randomly assigned to either standard group counseling (STND) or individualized relapse prevention (RP) aftercare. Heavier cocaine and alcohol use during IOP and low self-efficacy predicted more cocaine use during the treatment phase of the study, whereas lifetime diagnoses of alcohol dependence, major depression, and any anxiety disorder predicted less cocaine use. Rates of complete abstinence during the 6-month study period were higher in STND than RP, whereas RP was more effective in limiting the extent of cocaine use in those who used during Months 1-3. Matching analyses indicated patients who failed to achieve remission from cocaine dependence during IOP and those with a commitment to absolute abstinence did better in RP than in STND, whereas patients with other abstinence goals did better in STND than RP. Several differences in experiences before cocaine use and "near-miss" episodes were also identified.

Group counseling versus individualized relapse prevention aftercare following intensive outpatient treatment for cocaine dependence: initial results

Ninety-eight male cocaine-dependent patients who completed an intensive outpatient program (IOP) were randomly assigned to either standard group counseling (STND) or individualized relapse prevention (RP) aftercare. Heavier cocaine and alcohol use during IOP and low self-efficacy predicted more cocaine use during the treatment phase of the study, whereas lifetime diagnoses of alcohol dependence, major depression, and any anxiety disorder predicted less cocaine use. Rates of complete abstinence during the 6-month study period were higher in STND than RP, whereas RP was more effective in limiting the extent of cocaine use in those who used during Months 1-3. Matching analyses indicated patients who failed to achieve remission from cocaine dependence during IOP and those with a commitment to absolute abstinence did better in RP than in STND, whereas patients with other abstinence goals did better in STND than RP. Several differences in experiences before cocaine use and "near-miss" episodes were also identified.

The use of case vignettes for Addiction Severity Index training

In an attempt to enhance the reliability of Addiction Severity Index (ASI) interviewer severity ratings (ISRs), we developed a set of eight ASI vignettes, fictionalized narrative case summaries that reproduced the quantitative ASI information in case report format. Each vignette has an ISR answer key, a consensus ISR of two expert ASI trainers for each problem area. Additionally, for four of the vignettes the rationale for the correct ISRs was operationalized. This report is a description of the ASI vignette packet, its use as a supplement to standard ASI training and the results of a pilot study to gauge its effectiveness in improving criterion validity of ISRs. Five ASI videotapes were also developed for the purposes of this investigation. There was limited evidence in this preliminary investigation that the addition of the ASI vignette packet to standard ASI training increased agreement with expert consensus ISRs. The ASI vignettes, relative to videotaped or live observed interviews, do however provide a brief means of assessing the adequacy of ASI interviewer skills with regard to ISRs.

A cocaine-positive baseline urine predicts outpatient treatment attrition and failure to attain initial abstinence

The primary study objective was to ascertain whether a prior finding that the baseline cocaine urine toxicology predicted treatment dropout for cocaine dependent outpatients could be extended to three additional cocaine dependent outpatient treatment samples and whether the urine toxicology also predicted attainment of initial abstinence for the four samples. A secondary objective was to ascertain the extent to which other baseline variables accounted for additional outcome variance over and above that afforded by urine toxicology. To evaluate the first objective, the relationships between the baseline cocaine urine and each of two measures of within treatment response--the completion of treatment or the attainment of initial abstinence--were determined for each of the treatment samples. The second objective was evaluated by a stepwise, hierarchical logistic regression analysis, with the urine toxicology entered in the first step, baseline Addiction Severity Index (ASI) variables in the second step, and achievement of initial abstinence as the outcome. In all four samples, patients with a urine indicative of recent cocaine use were less than half as likely to complete treatment or achieve initial abstinence. Individual ASI baseline variables did not contribute statistically significant variance over and above that predicted by the cocaine urine toxicology. The findings confirm the utility of the initial cocaine urine as a predictor of unfavorable outpatient treatment response.

Social competence in opiate-addicted individuals: gender differences, relationship to psychiatric diagnoses, and treatment response

Only one prior study has examined social competence (SC) in drug addicted individuals. That study of cocaine-addicted individuals found gender differences in SC as well as differences based on the type of comorbid psychiatric diagnoses given. This study attempts to replicate findings from that cocaine study in a sample of opiate-addicted individuals and explores the relationship of SC to short-term treatment response. Gender differences in SC were examined in 28 women and 44 men attending a community methadone maintenance program. The question of differences in SC based on comorbid psychiatric diagnoses and treatment response were examined in a sample of 198 men attending a Veterans Administration methadone program. Women were found to have significantly lower SC than men. No significant differences in SC were revealed based on the presence of specific psychiatric diagnoses. SC was not related to short-term treatment response.

Validity of the psychopathy checklist-revised in male methadone patients

The psychopathy checklist-revised (PCL-R) has been shown to be reliable when used with male methadone patients, but validity has not been established in this population. This paper examines the PCL-R's validity in 251 male methadone patients. Correlations between the PCL-R and background variables, Axis I and Axis II disorders, and several self report measures of related constructs are evaluated. Correlations with Axis I disorders were low except for substance dependencies, but strong correlations between Cluster B personality disorders were found. Results provide evidence of construct validity for the PCL-R, particularly total and Factor 2 scores, in male methadone patients.

Response to methadone maintenance and counseling in antisocial patients with and without major depression

This study compared the treatment response of four groups of psychiatrically diverse opiate-dependent, methadone maintenance patients receiving drug counseling. The four groups were patients with no other nonsubstance abuse axis I psychiatric diagnoses (OP only; N = 65), patients with lifetime major depression (DEP; N = 60), patients with both antisocial personality disorder and lifetime major depression (APD + DEP; N = 35), and patients with only APD (APD only; N = 24). Patients were assessed at intake, during treatment, and 7 months after treatment admission. No statistically significant differences were found among the groups in treatment retention/attendance. Few significant group differences were revealed during-treatment urine screens, except that barbiturate use was more common for the APD only group. The APD only group also had significantly more positive urine screens for benzodiazepines than the other three groups at 7-month follow-up. All groups reported considerable improvement in problem level at 7 months compared with admission status. The APD only group reported fewer gains in legal and employment problems than the other groups but reported greater improvement in the drug area. Thus, there was some limited support for a prior finding, based on individual psychotherapy, that the treatment response of APD only patients was inferior to that of APD + DEP patients or non-APD patients.

Gender differences in the relapse experiences of cocaine patients

This study investigated potential gender differences in the onset, course, and termination of cocaine relapse episodes. The subjects were 98 cocaine dependent men and women who were participating in several treatment outcome studies. The Cocaine Relapse Interview was used to obtain data on specific relapse episodes that had occurred in a 6-month period before the interview. The analyses indicted that women reported more unpleasant affect and interpersonal problems and fewer positive experiences before relapse than men, and their relapses were more likely to have an impulsive quality. Women reported more help-seeking after initial use, whereas men reported stronger appetitive reactions and more self-justification. There were no gender differences in factors associated with terminating the relapse episodes. Clinical implications and limitations of the research are discussed.

Assessment of object relations and reality testing in methadone patients

OBJECTIVE

The authors studied methadone maintenance patients to determine the degree of their impairment in object relations and reality testing and the relationship of such impairment to comorbid axis I and axis II disorders. It was expected that deficits in object relations and, to a lesser degree, reality testing would be exhibited by the group as a whole and that they would be related to the presence of comorbid disorders.

METHOD

The self-report Bell Object Relations Reality Testing Inventory was administered to 240 methadone maintenance patients. The subjects were first divided into groups on the basis of number of comorbid axis I disorders and then on the basis of number of comorbid axis II disorders. Finally, the subjects were placed into one of four groups on the basis of the combined presence or absence of axis I and axis II disorders.

RESULTS

The methadone patients exhibited some specific impairments in object relations, but not in reality testing. Bell inventory scores did not significantly differ according to the number of comorbid axis I disorders, but they did significantly differ according to number of axis II disorders diagnosed. The scores were poorest for those with axis II disorders only, while subjects with only axis I disorders had scores similar to those with neither axis I nor II disorders.

CONCLUSIONS

Comorbid axis II disorders, more than axis I disorders, may be associated with problems in object relations and reality testing in methadone patients.

The relationship of object relations and reality testing deficits to outcome status of methadone maintenance patients

Impairments in the ability to form and maintain meaningful interpersonal relationships and in the ability to distinguish between internal and external stimuli are related to an individual's psychological health. The Bell Object Relations and Reality Testing Inventory (BORRTI) scores of 146 methadone patients were used to evaluate whether transitory (TI) or chronic impairments (CIs) in object relations and reality testing were related to more severe drug use, family and social problems, psychological distress, as well as more time in treatment, seeking additional treatments, or taking psychiatric medication. The results showed no significant relationship between BORRTI scores and family or social problems, time in treatment, or the months of heroin use between follow-up evaluations. However, severity of drug use was related to an impairment in a specific dimension of object relations-egocentricity. There was a significant relationship between TIs and CIs in object relations and reality testing with levels of psychological distress and the likelihood of taking psychiatric medication.

Personality disorders and treatment outcome in methadone maintenance patients

This study examined the relationship between personality disorder (PDs) and 7-month treatment outcome in 197 men admitted to methadone maintenance. Subjects reported pervasive improvement, and the amount of improvement did not significantly differ for those subjects with and without PDs. PD subjects entered treatment with more severe self-reported drug, alcohol, psychiatric, and legal problems, and despite progress, remained more problematic in those areas relative to subjects without PDs. Subjects with antisocial PD had admission and 7-month problem status similar to subjects with other PDs. The 7-month urinalysis results for opiates and cocaine showed no significant differences between subjects with and without PDs. Fewer PD subjects stayed in treatment continuously for the 7-month period. Several cluster B PDs-borderline, antisocial, and histrionic-predicted poorest overall outcomes. Methadone-maintained patients with PDs may warrant additional treatment services if they are to approach the functional level of patients without PDs.

Development of the cocaine relapse interview: an initial report

Although fine-grained analyses of circumstances surrounding relapses have been conducted with alcoholics, smokers and opiate users, there is comparatively little information about the relapse process in cocaine abusers. The Cocaine Relapse Interview (CRI) is a structured interview that gathers information on the onset, course and termination of cocaine relapse episodes. This article describes the development of the CRI and presents initial data on its reliability and validity. Sections of the CRI assess experiences on the day of the relapse, experiences during the week prior to the relapse, attributions for the relapse, experiences following initial use of cocaine and factors in terminating the relapse. Most of the subscales in each section of the CRI had adequate internal consistency and test-retest reliabilities. Validity studies indicated that most of the subscales that assess experiences prior to relapse differentiated relapsers from two control groups of non-relapsers, and that several subscales and individual items from the sections that assess experiences following initial use and factors in termination differentiated "lapsers" from "relapsers". Limitations of the CRI and recommendations for its use were also discussed.

An investigation of potential time effects in retrospective reports of cocaine relapses

Retrospective reports are widely used in social science research, such as studies of the relapse process. There is evidence, however, that such reports can be affected by a number of factors, including the passage of time. The goal of this study was to determine whether retrospective reports of cocaine relapses were influenced by the amount of time that had elapsed between the onset of the relapse and when the relapse interview was administered. A structured cocaine relapse interview was used to gather information on experiences prior to relapse and attributions for relapse. Evidence of linear and/or nonlinear time effects was found in two of the six subscales assessing experiences prior to relapse (Social Pressure to Use Drugs and Sensation Seeking), and there was evidence of logarithmic time effects in four of the six subscales that assessed attributions for relapses. These findings indicate that the amount of time between the onset of a relapse and when the subject is interviewed can influence reports of experiences prior to relapse and attributions for relapse. However, the magnitude of the time effects was generally small.

Gender differences in diagnosing antisocial personality disorder in methadone patients

OBJECTIVE

The goal of this study was to evaluate gender differences in the prevalence rates, short-term reliability, and internal consistency of the diagnosis of antisocial personality disorder for DSM-III-R, DSM-III, and Research Diagnostic Criteria (RDC).

METHOD

A total of 37 men and 57 women methadone patients were diagnosed according to DSM-III-R, DSM-III, and RDC antisocial personality disorder criteria.

RESULTS

The diagnostic rates, reliability, and internal consistency were lower for women than for men in all systems. DSM-III criteria resulted in the highest reliability for women, but for men, the DSM-III criteria were the least reliable. Examination of endorsement rates of individual antisocial personality disorder criteria revealed several significant gender differences on the majority of childhood criteria and on several adult criteria. Item-total correlations revealed that for women, the violent and aggressive childhood criteria in DSM-III-R that had not been included in DSM-III or RDC had a negative or no correlation to the assessment of antisocial personality disorder for women.

CONCLUSIONS

The change in DSM-III-R from DSM-III childhood criteria appears to have resulted in a decrease in internal consistency and rates of antisocial personality disorder for women, but not for men. The results of this investigation indicate that the psychometric properties of the current antisocial personality disorder scales are weak for women, compared with men. To assess antisocial personality disorder in women it may be necessary to revise current, or develop new, diagnostic criteria.

An examination of the cocaine relapse process

Although empirical studies of the relapse process have been done with alcoholics, smokers, and opiate addicts, comparatively little information is available on the relapse process in cocaine abusers. This paper presents data from the Cocaine Relapse Interview (CRI), a structured interview that assesses factors associated with the onset, course, and termination of cocaine relapse episodes. In a sample of 95 cocaine dependent patients, the experiences that occurred with the greatest frequency immediately prior to relapse were wanting drugs, being alone, having money, and feeling extremely bored and lonely. Following the onset of the relapse, the most frequent experience was unpleasant affect, although positive reactions were also relatively common. The factors perceived as most important in terminating relapse were painful internal states, help-seeking behaviors, and other coping responses. Three types of relapse experiences, or pathways, were identified: (a) unpleasant affect--painful internal states prior to and throughout the relapse; (b) positive affect--positive affect and pleasant social experiences prior to relapse coupled with a relatively unproblematic course; and (c) sensation seeking--sensation seeking and interpersonal problems prior to relapse coupled with mixed emotional reactions and antisocial behavior during the relapse, and interpersonal problems at relapse termination.

Treatment response of antisocial substance abusers

We evaluated the relationship of antisociality to 7-month treatment response in 224 alcohol-and/or cocaine-dependent men. Subjects with and without a DSM-III antisocial personality disorder (ASPD) responded similarly and positively to treatment in a number of functional domains, including substance use. A more detailed analysis comparing subjects with ASPD, subjects meeting adult but not childhood ASPD criteria (A-ASPD), and subjects meeting neither adult nor childhood ASPD criteria (pure non-ASPD) revealed similar and positive responses to treatment among the three groups. The antisocial groups had more cocaine and alcohol use at the baseline evaluation, but at 7-month follow-up, they had levels of use not significantly different than the pure non-ASPD group. The findings suggest that an ASPD diagnosis or an adult antisocial lifestyle, at least as measured by DSM-III criteria, does not predict short-term treatment response.

An examination of the diagnostic criteria for antisocial personality disorder in substance abusers

In this article, we compare problem severity and adult antisocial behavior among three groups of cocaine- or alcohol-dependent patients: those with antisocial personality disorder (APD), those who met adult but not childhood APD criteria (A-APD), and those who met neither (non-APD) in order to determine the clinical utility of the A-APD category. Subjects were 269 male veterans admitted for substance abuse treatment. The Addiction Severity Index was used to determine problem severity and the NIMH Diagnostic Interview Schedule was used to obtain positive DSM-III APD criteria and APD diagnoses. More APD subjects reported arrests, illegal behavior, and chronic lying than A-APD and non-APD subjects. On several variables (recent family/social problems, trouble controlling violent behavior, and time incarcerated), A-APD subjects were intermediate in severity. Overall, the non-APD subjects had the least severe problem status. When the APD and A-APD groups were equated on number of positive adult APD criteria, the only differences that consistently remained were difficulty controlling violent behavior and commission of criminal acts, which were endorsed more frequently in the APD group. It appears that the unique contribution of the early onset criteria for the APD diagnosis is that it identifies individuals more likely to engage in criminal and violent behavior. The more general irresponsibility and disregard for the rights of others characteristic of APD is equally evident in both antisocial groups. This work indicates that the APD versus non-APD distinction may not be fine grained enough for clinical or research purposes.

Parental relationships and substance use among methadone patients. The impact on levels of psychological symptomatology

The relationship between parental substance use problems (SUPs) and the quality of parental relationships with levels of psychological symptomatology was examined in 155 female and 324 male methadone maintenance patients. Subjects completed the Beck Depression Inventory (BDI), SCL-90, and the Treatment Effectiveness Questionnaire (TEQ), which included questions regarding demographics, drug use, family/social relationships, and substance use in relatives. Of those completing the questionnaire, 40% were randomly selected for an Addiction Severity Index (ASI) interview. As hypothesized, parental SUPs were associated with greater levels of psychological symptomatology, more family/social, and medical problems. Positive parental relationships were associated with significantly lower levels of psychological symptomatology and fewer family/social problems. Males were significantly more likely than females to report positive parental relationships and no parental SUPs. No differences based on race were revealed related to reports of the quality parental relationships or parental SUPs.

Relationships of personality disorders with problem severity in methadone patients

The prevalence of DSM-III-R personality disorders were assessed in a sample of 179 male methadone maintained opiate addicts. The discriminant validity of three personality disorder (PD) groupings were compared with respect to Axis I disorders, functioning in a number of important life areas, risk for HIV infection, and social judgment/sensitivity. Results showed that a PD, regardless of the number or type, identified patients with more employment, family/social, and psychiatric problems, increased risk for HIV infection, and poor social judgment/sensitivity. Few differences were revealed when three clusters of PDs (Cluster A, B, and C) were compared. With few exceptions, subjects with antisocial PD were no worse off than those with any other PD with respect to current functioning.

Addiction Severity Index scores of four racial/ethnic and gender groups of methadone maintenance patients

This report compares the findings for four racial/ethnic and gender groups of methadone maintenance (MM) patients--African-American men (n = 153), African-American women (n = 107), Hispanic men (n = 138), and Hispanic women (n = 70)--administered the Addiction Severity Index (ASI). African-American men had a history of more arrests and incarcerations than Hispanic men. African-Americans had a longer history of drug and alcohol abuse problems than Hispanics and more current alcohol problems. Women reported more medical, psychiatric, family-social, and employment problems than men. Men reported more legal and alcohol-related problems than women. With several exceptions, the study findings were consistent with those based on other instruments. Given the relatively large sample sizes, the data may provide a characteristic ASI profile of the racial/ethnic and gender groups studied. The implications of differential group problem levels for substance abuse treatment efforts are discussed.