A new brief screen for adolescent substance abuse

OBJECTIVE

To develop a brief alcohol and other drug (AOD) screening test for adolescents.

METHODS

A 9-item test was constructed by combining and modifying items from several AOD assessments, and administered concurrently with the Personal Involvement With Chemicals Scale (PICS), the criterion standard.

SETTING

A hospital-based adolescent clinic.

SUBJECTS

Fourteen- to 18-year-old patients consecutively arriving for routine medical care who were known to have used AOD.

MEASURES

Internal consistency of the 9 items was calculated using the Cronbach alpha. The relationship between the brief screen and PICS raw score was determined by stepwise linear regression analysis. The PICS T score has been shown to correctly classify substance abuse treatment need as no treatment (T<35), brief office intervention (T = 35-40), outpatient or short-term treatment (T = 41-54), and inpatient or long-term treatment (T> or =55). Sensitivity and specificity rates for predicting a PICS T score of 55 or higher were calculated from 2 x 2 tables.

RESULTS

Ninety-nine adolescents were tested (70.7% female, 36.4% black, 32.3% white, 19.2% Hispanic, mean age, 16.3 years). The 9 items had good internal consistency (Cronbach alpha = .79). Stepwise linear regression analysis identified 6 items whose total combined score was highly correlated with PICS (Pearson r = 0.84, P<.01). This model correctly classified 86% of subjects according to the PICS criteria. Two or more yes answers had a sensitivity of 92.3% and specificity of 82.1% for intensive AOD treatment need. The 6 items were arranged into a mnemonic (CRAFFT).

CONCLUSIONS

Further research must confirm the test's psychometric properties in a general clinic population. However, CRAFFT seems promising as a brief AOD screening test.

The Maudsley Addiction Profile (MAP): a brief instrument for assessing treatment outcome

AIM

To develop a brief, multi-dimensional instrument for assessing treatment outcome for people with drug and/or alcohol problems. The Maudsley Addiction Profile (MAP) is the first instrument to be developed in the United Kingdom for this purpose.

DESIGN

Field testing with quota-recruitment of problem drug users and problem alcohol users in treatment with researcher and clinician-administered test-retest interviews.

SETTING

Two community and two inpatient services at the Bethlem Royal and Maudsley Hospital, London.

PARTICIPANTS

Subjects (160 drug users and 80 alcohol users) interviewed by eight interviews (four researchers and four clinicians), each of whom interviewed 30 subjects on two occasions.

MEASURES

Sixty items across substance use, health risk, physical/psychological health and personal/social functioning domains.

FINDINGS

Average completion time of the MAP was 12 minutes. The questionnaire was acceptable to a majority of subjects and performed well with both researcher and clinician interviewers. Internal reliability and feasible concurrent validity assessments of the scales and items were highly satisfactory. Test-retest reliability was good, average intraclass correlation coefficients across eight substances were 0.94 and 0.81 across health risk, health problems, relationship conflict, employment and crime measures.

CONCLUSIONS

The MAP can serve as a core research instrument with additional outcome measures added as required. The collection of a set of reliable quantitative measures of problems among drug and alcohol users by research or treatment personnel for outcome evaluation purposes need not be time-consuming.

MCP-1, MCP-2 and MCP-3 expression in multiple sclerosis lesions: an immunohistochemical and in situ hybridization study

Chemokines are low molecular weight chemotactic cytokines that have been shown to play a central role in the perivascular transmigration and accumulation of specific subsets of leukocytes at sites of tissue damage. Two major families have been defined depending on the positioning of four conserved cysteines. The CXC chemokines predominantly attract neutrophils, whereas the CC chemokines predominantly attract monocytes and other leukocyte cell types. Members of the monocyte chemotactic protein (MCP)-1 family form a major component of the CC family of chemokines and are considered the principal chemokines involved in the recruitment of monocytes/macrophages and activated lymphocytes. In this study we addressed the expression and distribution of MCP-1, -2 and -3 in multiple sclerosis (MS) lesions of differing ages and levels of inflammatory activity using immunohistochemistry and in situ hybridization. In acute and chronic-active MS lesions immunoreactivity for MCP-1, -2 and -3 was prominent throughout the lesion center with reactivity diminishing abruptly at the lesion edge. Hypertrophic astrocytes were strongly reactive and inflammatory cells showed variable reactivity. Outside of the lesion only hypertrophic astrocytes were reactive. The results obtained by in situ hybridization for MCP-1 were in agreement with those obtained by immunostaining. In more chronic lesions immunoreactivity for MCP-1, -2 and -3 was considerably diminished, and in chronic-silent lesions immunoreactivity was restricted to a few scattered reactive astrocytes. Normal control brains showed no immunoreactivity for MCP-1, -2 and -3. Although the cellular distribution of all three members of this family was similar, antibodies to MCP-3 gave prominent staining of the extracellular matrix that was not noted for MCP-1 and -2. These results support the conclusion that members of the MCP family of chemokines are involved in the development of MS lesions in the central nervous system.

The National Psychiatric Morbidity surveys of Great Britain--initial findings from the household survey

BACKGROUND

This paper describes the Household Survey from the National Survey of Psychiatric Morbidity. This covered a sample drawn at random from the population of Britain, with the exception of the Highlands and Islands of Scotland.

METHODS

The Postcode Address file was used as the sampling frame. Nearly 13000 adults aged 16-65 were selected for interview, of whom 10108 (79.4%) were successfully interviewed. Eight per cent could not be contacted and 13% refused interview. Psychiatric assessment was carried out by lay interviewers using the CIS-R. Subjects were also screened for psychosis, and screen-positive individuals were examined by psychiatrists using SCAN.

RESULTS

Sixteen per cent of subjects scored above the standard cut-off of 12 on the CIS-R. The overall 1-week prevalence of neurotic disorder was 12.3% in males and 19.5% in females. Unmarried and post-marital groups had high rates of disorder, as did single parents and people living on their own. Respondents in Social Class I had notably lower rates of neurotic disorder than the remainder of the sample. Unemployment was strongly associated with disorder. Subjects living in urban areas had a higher overall prevalence, but there was no significant variation by region. Black respondents had higher rates of disorders that were entirely explained by their age, family type and social class. Individual neurotic disorders were all significantly commoner in women, with the exception of panic disorder. The 1-year prevalence of functional psychoses was 4 per 1000, with no sex difference. Alcohol and drug dependence was considerably more prevalent in men.

CONCLUSIONS

For the first time, the survey provides data on the prevalence and correlates of psychiatric disorder on a nationwide sample that can be used to inform equitable and effective national psychiatric services.

Methadone maintenance treatment in opiate dependence: a review

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The influence of age and sex on the prevalence of depressive conditions: report from the National Survey of Psychiatric Morbidity

BACKGROUND

Women are consistently reported to have a greater prevalence of depressive disorders than men. The reason for this is unclear, and is as likely to be social as biological. There is some evidence that the excess of depression is greater during women's reproductive lives. Data from the National Survey of Psychiatric Morbidity were used to test the hypothesis that the excess disappeared in the post-menopausal years and that obvious social explanations for this were inadequate.

METHOD

Subjects (N = 9792) from a random sample of the British population provided data for the analysis. Psychiatric assessment was carried out by lay interviewers using the CIS-R. Subjects with ICD-10 depressive episode or mixed anxiety/depression were compared with the remainder. Social variables that were likely to contribute to a post-menopausal decline in depressive disorders were controlled in logistic regression analyses.

RESULTS

There was a clear reversal of the sex difference in prevalence of depression in those over age 55. This could not be explained in terms of differential effects of marital status, child care, or employment status.

CONCLUSIONS

This large and representative survey adds considerably to the increasingly held view that the sex difference in prevalence of depression is less apparent in later middle age. This may be linked to the menopause, and our attempts to explain it in terms of obvious conditions among social variables were not successful. More specific studies are required to clarify the finding.

Nicotine, alcohol and drug dependence and psychiatric comorbidity. Results of a national household survey

BACKGROUND

There is a well-recognised relationship between substance use disorders and other psychiatric disorders. This relationship has been well documented in a range of population-based studies.

AIMS

This study aims to report on consumption patterns of and dependence on nicotine, alcohol and non-prescribed drugs and to report on the levels of psychiatric morbidity in these groups.

METHOD

A national household study of psychiatric morbidity was conducted in England and Wales. Psychiatric assessment was based on the Clinical Interview Schedule-Revised (CIS-R). Measures of nicotine, alcohol and drug use and dependence were obtained. This paper compares the levels of psychiatric morbidity in the non-dependent and the nicotine-, alcohol- and drug-dependent cases.

RESULTS

Twelve per cent of the non-dependent population were assessed as having any psychiatric disorder compared with 22% of the nicotine-dependent, 30% of the alcohol-dependent and 45% of the drug-dependent population.

CONCLUSIONS

There is a clear relationship between dependence on nicotine, alcohol and drugs and other psychiatric morbidity.

Debt, income and mental disorder in the general population

BACKGROUND

The association between poor mental health and poverty is well known but its mechanism is not fully understood. This study tests the hypothesis that the association between low income and mental disorder is mediated by debt and its attendant financial hardship.

METHOD

The study is a cross-sectional nationally representative survey of private households in England, Scotland and Wales, which assessed 8580 participants aged 16-74 years living in general households. Psychosis, neurosis, alcohol abuse and drug abuse were identified by the Clinical Interview Schedule--Revised, the Schedule for Assessment in Neuropsychiatry (SCAN), the Alcohol Use Disorder Identification Test (AUDIT) and other measures. Detailed questions were asked about income, debt and financial hardship.

RESULTS

Those with low income were more likely to have mental disorder [odds ratio (OR) 2.09, 95% confidence interval (CI) 1.68-2.59] but this relationship was attenuated after adjustment for debt (OR 1.58, 95% CI 1.25-1.97) and vanished when other sociodemographic variables were also controlled (OR 1.07, 95% CI 0.77-1.48). Of those with mental disorder, 23% were in debt (compared with 8% of those without disorder), and 10% had had a utility disconnected (compared with 3%). The more debts people had, the more likely they were to have some form of mental disorder, even after adjustment for income and other sociodemographic variables. People with six or more separate debts had a six-fold increase in mental disorder after adjustment for income (OR 6.0, 95% CI 3.5-10.3).

CONCLUSIONS

Both low income and debt are associated with mental illness, but the effect of income appears to be mediated largely by debt.

Monoclonal antibody therapy of malignant melanoma: in vivo localization in cutaneous metastasis after intravenous administration

The murine antimelanoma monoclonal antibody, 9.2.27, was administered intravenously to eight patients with metastatic malignant melanoma. Biopsies of metastatic nodules clearly demonstrate the selective localization of this antibody on the melanoma cell surface with a dose-response relationship to the quantity of administered antibody. The antibody infusions were clinically well tolerated and the pharmacokinetics of the antibody and the antiglobulin responses are described. This study indicates that murine monoclonal antibodies have potential as selective targeting agents in the design of future therapeutic trials using monoclonal antibodies or conjugates thereof in the treatment of cancer.

A review of biological indicators of illicit drug use, practical considerations and clinical usefulness

AIMS

To examine a range of biological indicators of illicit drug use, including blood, urine, hair and saliva, addressing both technological and practical issues relating to their application and interpretation.

METHODS

The review process involved an examination of key reference texts and literature from the scientific fields of analytical and clinical toxicology.

FINDINGS

Urine remains the biological tool of choice for qualitative detection of illicit drug use in a clinical setting, while quantitative accuracy remains strictly the domain of blood. The growing sophistication of laboratory analysis may additionally make possible the routine use of hair sampling which can provide a much longer time frame for assessment. Breath, saliva, sweat or breast milk remain possibilities in the future.

CONCLUSIONS

Accurate interpretation of the screening tests within a clinical setting alongside other relevant information remains the key to the usefulness of any test.

Unequal access and unmet need: neurotic disorders and the use of primary care services

BACKGROUND

In this paper we use data from the National Survey of Psychiatric Morbidity to examine how many people with neurotic disorders receive professional evaluation, and how this is affected by clinical and sociodemographic differences. We hypothesized that psychiatric symptoms and attendant dysfunctions would both have an effect on contacting, and that key demographic variables would not.

METHOD

The household component of the British National Surveys of Psychiatric Morbidity was based on a random sample of > 10,000 subjects. Psychiatric symptoms and ICD-10 diagnosis were established by lay interviewers using the CIS-R. Social dysfunction was tapped by asking about difficulties in performing seven types of everyday activity. We examined symptom score, ADL deficit score and demographic variables in relation to contact with primary care physicians for psychiatric symptoms.

RESULTS

The major determinant of contacting a primary care physician was severity, mainly due to the level of psychiatric symptoms, but with an independent contribution from social dysfunction. There were also significant contributions from sex, marital status, age, employment status and whether the subject had a physical condition as well.

CONCLUSIONS

The major influence on whether people seek the help of their family doctors for mental health problems is the severity of disorder. Although there are some social inequalities in access to family doctors, these are less important. The most salient finding from our study is that even people suffering from high levels of psychiatric symptoms very often do not have contact with professionals who might help them.

Microbial utilisation of biochar-derived carbon

Whilst largely considered an inert material, biochar has been documented to contain a small yet significant fraction of microbially available labile organic carbon (C). Biochar addition to soil has also been reported to alter soil microbial community structure, and to both stimulate and retard the decomposition of native soil organic matter (SOM). We conducted a short-term incubation experiment using two (13)C-labelled biochars produced from wheat or eucalypt shoots, which were incorporated in an aridic arenosol to examine the fate of the labile fraction of biochar-C through the microbial community. This was achieved using compound specific isotopic analysis (CSIA) of phospholipid fatty acids (PLFAs). A proportion of the biologically-available fraction of both biochars was rapidly (within three days) utilised by gram positive bacteria. There was a sharp peak in CO2 evolution shortly after biochar addition, resulting from rapid turnover of labile C components in biochars and through positive priming of native SOM. Our results demonstrate that this CO2 evolution was at least partially microbially mediated, and that biochar application to soil can cause significant and rapid changes in the soil microbial community; likely due to addition of labile C and increases in soil pH.

Psychiatric symptoms among clients seeking treatment for drug dependence. Intake data from the National Treatment Outcome Research Study

BACKGROUND

Many people with substance use disorders are vulnerable to other psychiatric disorders and present to addiction treatment services with comorbid psychiatric symptoms.

AIMS

To describe the prevalence of recent psychiatric treatment and current psychiatric symptoms and explore links between substance misuse, personal/social functioning and symptom severity.

METHOD

Subjects were 1075 adults recruited to the National Treatment Outcome Research Study (NTORS), of whom 90% were opiate-dependent. Psychiatric symptoms at intake were recorded using sub-scales from the Brief Symptom Inventory.

RESULTS

Recent psychiatric treatment was reported by one in five subjects. Psychiatric symptom levels were high and females had elevated scores on all scales. Symptoms were elevated among opiate users who were also frequent users of benzodiazepines, alcohol and, in particular, stimulants. Gender, physical health, drug dependence and personal relationship problems were more powerful predictors of psychiatric symptoms than substance use.

CONCLUSIONS

Addictions service providers should be vigilant to psychiatric problems among their clients at intake to treatment. Psychiatric symptoms are more closely linked to polydrug use than to opiate use in this population.

The influence of age and sex on the prevalence of depressive conditions: report from the National Survey of Psychiatric Morbidity

Women are consistently reported to have a greater prevalence of depressive disorders than men. The reason for this is unclear, and is as likely to be social as biological. There is some evidence that the excess of depression is greater during women's reproductive lives. Data from the National Survey of Psychiatric Morbidity were used to test the hypothesis that the excess disappeared in the post-menopausal years and that obvious social explanations for this were inadequate. Subjects (n = 9792) from a random sample of the British population provided data for the analysis. Lay interviewers using the CIS-R carried out psychiatric assessment. Subjects with ICD-10 depressive episode or mixed anxiety/depression were compared with the remainder. Social variables that were likely to contribute to a post-menopausal decline in depressive disorders were controlled in logistic regression analyses. There was a clear reversal of the sex difference in prevalence of depression in those over age 55. This could not be explained in terms of differential effects of marital status, childcare, or employment status. This large and representative survey adds considerably to the increasingly held view that the sex difference in prevalence of depression is less apparent in later middle age. This may be linked to the menopause, and our attempts to explain it in terms of obvious conditions among social variables were not successful. More specific studies are required to clarify the finding.

Psychosis and drug dependence: results from a national survey of prisoners

BACKGROUND

The links between drug use and psychosis are of major aetiological and prognostic significance. Psychosis and drug dependence frequently co-occur within the prison population, providing the opportunity to study this link more closely.

AIMS

To explore the relationship between psychosis and drug dependence in a sample of prisoners.

METHOD

A total of 3142 prisoners were surveyed nationally, and structured clinical data were obtained from a subsample of 503 respondents. Psychiatric assessment was based on the Schedules for Clinical Assessment in Neuropsychiatry (version 1.0). Measures of amphetamine, cannabis, cocaine and heroin use and dependence were obtained through self-report.

RESULTS

Logistic regression analyses indicated that first use of amphetamines or cocaine before the age of 16 years and severe cannabis or cocaine dependence were related to an increased risk of psychosis. In contrast, severe dependence on heroin was associated with a reduced risk of this classification.

CONCLUSIONS

Severe dependence on cannabis and psychostimulants is associated with a higher risk of psychosis and is in contrast to severe dependence on heroin, which has a negative relationship with psychosis.

Opiate withdrawal

Opiate withdrawal is one of the longest studied and most well described withdrawal syndromes. Opiate withdrawal has been described as akin to a moderate to severe flu-like illness. Opiate withdrawal is appropriately described as subjectively severe but objectively mild. This paper describes the mechanisms of opiate dependence and opiate withdrawal and reviews the available instruments for the measurement of withdrawal. The time course of assisted and unassisted withdrawal is described and the range of options for the management of assisted withdrawal are described. This review concludes that the most effective and least time- and resource-consuming approach to opiate withdrawal will substantially contribute to the overall social management of opiate dependence.

Socioeconomic status, standard of living, and neurotic disorder

BACKGROUND

Evidence on the association between socioeconomic status and the prevalence of neurotic disorder is contradictory. We studied the association between three elements of socioeconomic status and the prevalence of neurotic psychiatric disorder in a representative sample of adults aged 16-64 living in private households in the UK.

METHODS

A cross-sectional survey of 10,108 adults aged 16-65 resident in private households in the UK was selected by a multi-stage, clustered, random-sampling design. Neurotic disorders were defined using a standardised interview, the revised clinical interview schedule (CIS-R). Data for 9570 people were available for this study.

FINDINGS

We used housing tenure and access to cars as measures of standard of living; both were associated with the prevalence of neurotic disorder even after adjustment for other socioeconomic and demographic variables, including Registrar General's Social Class and educational attainment. Those people with no access to a car had an odds ratio for neurotic disorder of 1.4 (95% CI 1.1-1.7), compared with those who had access to two or more cars. People who rented their homes were also at increased risk (1.3 [1.1-1.5]). We estimated that about 10% of the neurotic disorder in the UK could be attributed to the increased prevalence of those without cars who rented their homes. There was a complex interaction between Registrar General's Social Class and sex, and there was no independent association with educational attainment.

INTERPRETATION

There is an independent association between low standard of living and the prevalence of neurotic psychiatric disorder. The UK has experienced one of the largest increases in income inequality within western market economies over the past 20 years, and this inequality may have had adverse consequences for the mental health of the population.

Biochar modulates heavy metal toxicity and improves microbial carbon use efficiency in soil

Soil organic carbon is essential to improve soil fertility and ecosystem functioning. Soil microorganisms contribute significantly to the carbon transformation and immobilisation processes. However, microorganisms are sensitive to environmental stresses such as heavy metals. Applying amendments, such as biochar, to contaminated soils can alleviate the metal toxicity and add carbon inputs. In this study, Cd and Pb spiked soils treated with macadamia nutshell biochar (5% w/w) were monitored during a 49days incubation period. Microbial phospholipid fatty acids (PLFAs) were extracted and analysed as biomarkers in order to identify the microbial community composition. Soil properties, metal bioavailability, microbial respiration, and microbial biomass carbon were measured after the incubation period. Microbial carbon use efficiency (CUE) was calculated from the ratio of carbon incorporated into microbial biomass to the carbon mineralised. Total PLFA concentration decreased to a greater extent in metal contaminated soils than uncontaminated soils. Microbial CUE also decreased due to metal toxicity. However, biochar addition alleviated the metal toxicity, and increased total PLFA concentration. Both microbial respiration and biomass carbon increased due to biochar application, and CUE was significantly (p<0.01) higher in biochar treated soils than untreated soils. Heavy metals reduced the microbial carbon sequestration in contaminated soils by negatively influencing the CUE. The improvement of CUE through biochar addition in the contaminated soils could be attributed to the decrease in metal bioavailability, thereby mitigating the biotoxicity to soil microorganisms.

Substance misuse and psychiatric comorbidity: an overview of the OPCS National Psychiatric Morbidity Survey

There have been a number of national surveys of psychiatric morbidity which have included questions on drugs, alcohol and tobacco. These surveys have helped delineate the overlap between substance use and dependence and other psychological morbidity. There is a strong association reported between high substance consumption and other measures of psychological problems. This article provides an overview of a national household survey, a survey of institutional residents with psychiatric disorders and a national survey of a homeless population. All three surveys used comprehensive and complex sampling strategies and lay interviewers to conduct structured diagnostic interviews. The household survey included over 10,000 households, the institutional survey interviewed 755 individuals and the homeless survey of hostels, night-shelters, day centres and private-sector leased accommodation interviewed 1,061 individuals. This overview looks at patterns of nicotine, alcohol and other drug use in the different samples and examines interactions with other psychiatric morbidity. The survey reports that substance-related disorders are some of the commonest disorders in the community, with 5% of the household sample alcohol dependent, 7% alcohol dependent in the institutional sample and over 21% in the homeless sample recorded as alcohol dependent. Tobacco, alcohol and other drug use and dependence were dramatically higher in the homeless sample than in either of the other two samples. Substance use was significantly associated with higher rates of psychological morbidity as measured by the Clinical Interview Schedule Revised. Future service planning needs to take account of the striking disparity of prevalence of psychiatric disorders in different subsections of the population.

A prospective study of complications associated with cuffed, tunnelled haemodialysis catheters

BACKGROUND

Despite the US Dialysis Outcome Quality Initiative )DOQI( guidelines, for various reasons, increasing numbers of end-stage renal disease patients are becoming dependent on cuffed haemodialysis catheters (HCs) for chronic haemodialysis access. Their use is complicated by frequent failure due to thrombosis and catheter-related sepsis. In our unit, all HCs are put in place by the radiology department.

METHODS

In a prospective study we looked at the outcome of all HCs over a three-year period, during which time 573 consecutive HCs were placed in 336 patients. Each line was followed individually until it was removed or until the end of the study.

RESULTS

In a survival analysis of those HCs removed following HC failure, HC half-life was 312 days and one-year HC survival was 47.5%. The most frequent indications for HC removal were non-function (36.6%), clinical suspicion of line sepsis (16.4%) and patient death (14.4%). Using a Cox proportional hazards model, catheter number in a given patient and the presence of diabetes mellitus were found to be independent predictors of HC failure. The total incidence of HC-related sepsis was 1.3 episodes/1000 catheter days. The probability of developing bacteraemic HC-related sepsis was 27.5% at one year.

CONCLUSIONS

Less than half of the HCs were removed electively because of availability of a more permanent mode of renal replacement, thereby illustrating the level of dependence that has developed on them as permanent access. Consequently, their limitations (infection and malfunction) are placing an ever increasing burden on the healthcare services.

Neurotic disorders and the receipt of psychiatric treatment

BACKGROUND

Access to psychiatric treatment by people with neurotic disorders in the general population is likely to be affected both by the severity of disorder and by sociodemographic differences.

METHOD

In the household component of the National Surveys of Psychiatric Morbidity > 10,000 subjects in Great Britain with psychiatric symptoms were interviewed using the CIS-R. They were also asked about difficulties experienced in performing seven types of everyday activity. All subjects classed as having an ICD-10 disorder were questioned about their experience of treatment with antidepressants, hypnotics, and counselling or psychotherapy.

RESULTS

Less than 14% of people with current neurotic disorders were receiving treatment for them. Within the previous year, only a third had made contact with their primary care physician for their mental problem: of these < 30% were receiving treatment. Overall, 9% of people with disorders were given medication and 8% counselling or psychotherapy. A diagnosis of depressive episode was that most associated with antidepressant medication. Treatment access was affected by employment status, marital status, and age, but the major determinant was symptom severity. Neither sex nor social class influenced which people received treatment.

CONCLUSIONS

People with psychiatric disorders seldom receive treatment, even when they have consulted their primary care physician about them. In many cases, this must represent unmet needs with a strong claim on health resources. There are also inequalities in the receipt of treatment, although the major influence is the severity of disorder.