Faculty Bibliography

In order to explore the association between verbal deficits and disruptive behavior disorders among children of addicted parents, 283 6-17-year-old children and their opiate-dependent parents completed diagnostic interviews and standardized measures of vocabulary. Unexpectedly, racial differences in the scores confounded the exploration of the relationship between cognitive scores and disruptive behavior disorders. An interaction between disruptive behavior disorder and race is explored; among Caucasian youths, low verbal scores are associated with disruptive behavior disorders, but this association was not found among African- and Hispanic-American youths. Further analysis and research are needed to understand the clinical significance of relationships between verbal deficits and disruptive behavior disorders within racially diverse groups.

BACKGROUND:The clinical and etiologic implications of comorbid psychiatric and substance-use disorders are relevant across countries and cultures. The DSM-IV now places greater emphasis on the clinical and research utility of the substance-induced disorders classification, and clarifies several important diagnostic issues specific to primary and substance-induced disorders. However, no research consensus exists over the core problem of identifying and differentiating the drug and alcohol intoxication and withdrawal symptoms that can mimic psychiatric symptoms in heavy drinkers and drug users. OBJECTIVE:To investigate how various diagnostic instruments have measured comorbid psychiatric and substance-use disorders and how each instrument operationalizes the DSM-IV classification. METHOD/METHODS:We review the evolution of the concept of comorbidity beginning with its formalization as the 'primary-secondary' distinction in the Feighner Criteria. We address the 'organic-non-organic' distinction found in the RDC, DSM-III, and DSM-III-R; and finally, review the 'primary' and 'substance-induced' categories of DSM-IV, DSM-IV-TR and ICD-10. We describe how these distinctions have been operationalized in widely used diagnostic instruments. CONCLUSION/CONCLUSIONS:Further understanding of these classifications and the relationship of co-occurring psychiatric and substance disorders can be accomplished with the range of available measures, particularly the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), which reliably utilizes and refines DSM-IV classification distinctions.

Patients with both depression and drug dependence are at an elevated risk for suicide, yet suicide remains rare and difficult to predict. Clinical and demographic features associated with suicide risk among depressed opiate-dependent patients were examined using baseline data from the Addiction Severity Index and Hamilton Depression Scale. Female gender, violent behavior in the past thirty days and lifetime, and less education correlated with a history of suicide attempts. Family conflict and depression severity correlated with current suicidal ideation. When evaluating opiate-dependent patients with depressive disorders, these features should be considered in efforts to identify those at heightened risk for suicide and plan interventions.

Depression is common among opiate-dependent patients and has been associated with worse prognosis. This article reviews the literature on treatment of depressive disorders and symptoms among patients with opiate dependence. Depression bears a complex relationship to opiate dependence and may represent an independent disorder or may be engendered by psychosocial stress or toxic and withdrawal effects of drugs. Primary treatments for opiate dependence (e.g., methadone or buprenorphine maintenance or residential treatment) are associated with substantial improvements in depression. Studies of antidepressant medications have produced mixed results, some positive but more negative. It is not clear what accounts for these differences, and more research is needed to determine how to select opiate-dependent patients most likely to benefit from antidepressants. Fewer studies have examined psychosocial or behavioral interventions, but some of these also show promise. The data suggest a stepped model of care in which depression is evaluated and observed during the outset of treatment for opiate dependence and if it does not improve, specific psychosocial interventions or antidepressant medications tried. Research is needed on such integrated models of care and treatment algorithms to determine their efficacy and cost effectiveness.

Cognitive-behavioral therapy (CBT) depends on adequate cognitive functioning in patients, but prolonged cocaine use may impair cognitive functioning. Therefore, cognitive impairment may impede the ability of cocaine abusers to benefit from CBT. To begin to address this issue, we investigated the relationship between cognitive impairment and two treatment outcomes, therapy completion and abstention. Eighteen carefully screened non-depressed cocaine-dependent patients in a psychopharmacological clinical trial were administered the MicroCog computerized battery to assess cognitive performance at treatment entry. T-tests were used to compare cognitive functioning between completers (patients remaining in treatment at least 12 weeks) and dropouts. The results indicated that treatment completers had demonstrated significantly better cognitive performance at baseline than patients who dropped out of treatment. Cognitive domains that significantly distinguished between treatment completers and dropouts were attention, mental reasoning and spatial processing. This study provides preliminary evidence that cognitive impairments may decrease treatment retention and abstinence in CBT of cocaine dependence.

This special issue represents an effort by the journal Experimental and Clinical Psychopharmacology to emphasize its interdisciplinary mission by encouraging the writing of articles on clinical research and the interchange between basic and clinical research on mental illness and the addictions. This special issue opens with a commentary from A. I. Leshner (2002), retired director of the National Institute on Drug Abuse, which emphasizes the importance of translating research findings into clinical practice. Four review articles and 12 original research reports provide a broad sampling of contemporary clinical research, including behavioral therapy, pharmacotherapy, psychiatric comorbidity, and special populations, and also illustrate linkages between clinical research and basic fields of inquiry, including behavioral theory, neuropsychology, neuropharmacology, and statistics.

OBJECTIVE:The authors' goal was to investigate whether subtypes of DSM-IV depression predict suicidal behavior among patients with substance dependence. METHOD/METHODS:Major depression among 602 patients with substance dependence was classified as occurring before dependence, during abstinence, or exclusively during periods of substance use. Analyses of patients with the three types of depression included logistic and linear regression. RESULTS:All three types of depression increased the risk for making a suicide attempt. Major depression that occurred before the patient became substance dependent predicted severity of suicidal intent. Major depression that occurred during abstinence predicted number of attempts. CONCLUSIONS:These results suggest the importance of establishing DSM-IV subtypes of depression based on the timing of the occurrence of depression in relation to substance dependence in evaluating suicidal risk among substance-dependent patients.

There are few published studies assessing the efficacy of pharmacologic treatments for attention-deficit hyperactivity disorder (ADHD) among substance abusers seeking treatment. Eleven patients who met DSM-IV diagnostic criteria for cocaine dependence and adult ADHD were entered into a 12-week single-blind trial of divided daily doses of bupropion (BPR). All patients received weekly individual standardized relapse prevention therapy. Treatment compliance and retention were good. Patients reported significant reductions in attention difficulties, hyperactivity and impulsivity. Self-reported cocaine use, cocaine craving, and cocaine positive toxicologies, also decreased significantly. In a previously published trial, 12 patients who met similar diagnostic criteria for adult ADHD and cocaine dependence were entered into a 12-week trial of divided daily doses of sustained-release methylphenidate (MPH). Improvements observed on BPR were similar to, and did not differ from those previously observed with MPH. These preliminary data suggest that BPR may be as effective as sustained-release MPH, when combined with relapse prevention therapy, for cocaine abusers with adult ADHD. However, a future study directly comparing BPR to MPH in a double-blind placebo-controlled trial is needed.

Cannabis is the most widely used illegal drug in the U.S. population. Surveys have estimated that the lifetime prevalence rate for cannabis dependence is approximately 4%. Though the presence of a psychiatric disorder increases the likelihood of developing substance dependence, the field lacks data regarding the association between mental disorders and cannabis dependence. The aim of this study is to describe the prevalence of psychiatric disorders among individuals with cannabis dependence. The National Comorbidity Survey was used to obtain these data. We found that 90% of respondents with cannabis dependence had a lifetime mental disorder, compared to 55% without cannabis dependence. Alcohol dependence, antisocial personality disorder, and conduct disorder had the strongest associations with cannabis dependence, followed by anxiety and mood disorders. A large proportion of respondents with internalizing disorders developed mood or anxiety disorders prior to onset of their first cannabis dependence symptom. Data regarding the prevalence of comorbid mental disorders underscore the importance of thorough and systematic evaluation of patients seeking treatment for cannabis dependence. The failure to identify comorbidity may lead to inadequate treatment, and a poorer prognosis.