Faculty Bibliography

This study examined rates of psychiatric disorders and impairment in 283 children, aged 6 to 17, of 69 Caucasian, 45 African-American, and 47 Hispanic-American methadone maintenance patients. Children were evaluated by direct and/or parental interview with the K-SADS-E. Final DSM-III-R diagnoses and Global Assessment Scale (C-GAS) were assigned by best estimate. Substantial lifetime prevalences of mood (21%), anxiety (24%) and disruptive disorders (30%), school problems (37%), and global impairment (C-GAS < 61) (25%) were observed in the children of opiate-dependent patients. There were few differences between ethnic groups. Effects of proband gender and major depression and their interactions with ethnicity on risk for childhood psychopathology were also examined. The results suggest children of patients in treatment for opiate dependence from diverse ethnic groups are at risk for psychopathology. Programs for early detection and intervention should be devised and evaluated.

The increased risk of physical health problems in adult depressed patients has been shown in numerous studies. A recent study of the offspring of depressed parents found similar associations. The purpose of this study is to examine the strength and specificity of the association between depression and physical health problems in children and adolescents whose parents are dependent upon opiates. The sample consisted of offspring ages 6-17 (mean age 11 years) of opiate addicts who had a history of major depressive disorder (MDD; n = 28); other mood disorders (n = 31); no history of mood disorders but other psychiatric disorders (n = 92); or no history of psychiatric disorder (n = 127). Detailed psychiatric assessment and medical history of the offspring by direct interview with the offspring and an informant were obtained blind to parental diagnosis. After controlling for possible confounders, there was an increased risk of dermatological disorders, headache, other neurological/neuromuscular disorders, bronchitis, other respiratory disorders and hospitalizations for nonsurgical procedures in offspring with MDD, as compared to nonpsychiatrically ill controls. The offspring with other mood disorders had a slightly elevated risk. Major depression in children and adolescents whose parents are dependent on opiates is associated with increased risk of physical health problems. This finding is consistent with other reports and the timing of the physical health problems requires further study.

There are few systematic studies of the school-aged offspring of drug-dependent patients, although this information is useful for planning evidence-based prevention programs. We have completed such a study, which we compare to a similar study independently conducted in 1998. In both studies, both the parent and offspring were assessed blindly and independently by direct diagnostic interviews, and parental assessment of offspring was also obtained. The similarity in design and methods between studies provided an opportunity for replication by reanalysis of data. The major findings are a replication in two independently conducted studies of school-aged offspring of opiate- and/or cocaine-addicted mothers of the high rates of any psychiatric disorder (60% in both studies), major depression (20%, 26%), oppositional defiant disorder (ODD) (18%, 23%), conduct disorder (17%, 9%), attention-deficit/hyperactivity disorder (ADHD) (13%, 8%), and substance abuse (5%, 10%) among offspring. Both studies also found high rates of comorbid alcohol abuse, depression, and multiple drugs of abuse in the mothers. We conclude that efforts to replicate findings by analyses of independently conducted studies are an inexpensive way to test the sturdiness of findings that can provide the empirical basis for preventive efforts. Clinically, the data in both studies suggest that both drug dependence and associated psychopathology should be assessed and treated in opiate addicts with young offspring, and the offspring should be monitored for the development of conduct and mood disorders and substance use.

A small, controlled study was conducted to assess whether pergolide mesylate has clinical promise as a treatment for cocaine abuse prior to embarking on a larger, randomized, double-blind, controlled trial. Fourteen individuals were placed on placebo for 2 weeks, followed by a 24-week single-blind study in which they were placed on pergolide for 12 weeks, followed by placebo for 12 weeks. Another 14 patients received single-blind placebo for two weeks and then were randomized into a 24-week double-blind, placebo-controlled, multiple baseline design. Initially, patients enrolled in the study were placed on risperidone (n = 9) or placebo (n = 5). During the first 12 weeks, retention was worse for those receiving pergolide compared to risperidone or placebo. Neither risperidone nor pergolide were more efficacious in reducing cocaine use than placebo. Although earlier open studies found pergolide to show promise as a treatment for cocaine abuse, this study did not support these earlier findings. Comparing an agent to both an active control and placebo group may better predict whether a promising new agent will have clinical utility compared to the standard open trial.

The treatment and research of dissociative disorders, particularly dissociative identity disorder (DID), are hampered by professional skepticism and diagnostic uncertainties. Almost always associated with severe and sustained childhood trauma, its chief manifestations are at least two distinct and separate identities which have an independent manner of existing in the world. It is also associated with a high degree of psychiatric comorbidity. Among the most frequent diagnoses found in patients with DID are substance use and dependence. For a variety of reasons there has been little dialogue among the disciplines that study patients with trauma and those that study and treat substance abuse. Clinicians dealing with a primarily substance-abusing population are likely to encounter but not recognize these patients. The authors present several representative cases illustrative of features of patients with DID. The epidemiology, phenomenology and presentation of DID, as well as its relation to posttraumatic stress disorder are discussed. Little systematic investigation exists on the treatment of DID in general, and substance abuse in DID in particular. The authors draw upon the existing literature, and their experience to discuss treatment strategies aimed at treating patients with both diagnoses. Ignoring either diagnosis is likely to be detrimental to patients; both disorders and their coexistence need to be addressed.

BACKGROUND:The literature is inconclusive on the role of antidepressant medications in treating drug dependence. Studies have either not focused on depressed patients or have selected patients with depressive disorders based on cross-sectional symptoms rather than a syndromal diagnosis. A clinical trial of an antidepressant was, therefore, conducted on drug-dependent patients with syndromal depression. METHODS:Patients receiving methadone hydrochloride maintenance treatment were selected if they met the criteria for a DSM-III-R depressive disorder that was chronologically primary, had persisted during a past abstinent period or was long-standing, and persisted during at least 1 month of stable methadone treatment. Subjects were randomized to a 12-week, double-blind, placebo-controlled trial of imipramine hydrochloride. A favorable response was defined as a Clinical Global Impression scale score for depression of 2 ("much improved") or 1 ("very much improved") and at least a 75% reduction in self-reported drug or alcohol use or abstinence. RESULTS:One hundred thirty-seven patients were randomized, and 84 completed a minimum adequate trial of at least 6 weeks. Among the 84 adequately treated patients, 57% (24/42) receiving imipramine were rated as responders compared with 7% (3/42) receiving placebo (P < .001). On measures of mood, there was a robust effect of imipramine. Imipramine was superior to placebo on some self-reported measures of substance use and craving, and mood improvement was associated with improvement in self-reported substance use. However, few patients achieved urine-confirmed abstinence. CONCLUSIONS:Imipramine was an effective antidepressant in patients receiving methadone who were selected via syndromal criteria for depressive illness. Imipramine may reduce substance abuse among patients whose mood improves; however, this effect was less robust.

OBJECTIVE:To evaluate psychiatric disorders and impairment in school-age and adolescent children of opiate-dependent patients. METHOD/METHODS:One hundred fourteen children, aged 6 to 17 years, of 69 white methadone maintenance patients with (n = 30) and without (n = 39) major depression were evaluated for DSM-III-R diagnoses by the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version and best estimate, and by measures of functioning (Children's Global Assessment Scale, Social Adjustment Inventory for Children and Adolescents, WISC, Peabody Picture Vocabulary Test), and compared with children of historical controls without substance abuse history. RESULTS:Sons of opiate addicts with major depression were at increased risk for conduct disorder and global, social, and intellectual impairment compared with sons of opiate addicts without major depression and/or sons of controls with neither drug dependence nor depression. Sons of opiate addicts without major depression differed little from controls. Daughters of opiate addicts did not differ from controls in rates of disorders but had poorer social adjustment and nonverbal intelligence. CONCLUSIONS:Children of opiate-dependent patients, particularly sons of addicts with depression, may be at risk for a developmental path toward antisocial personality and poor social and intellectual functioning. Treatment settings such as methadone maintenance might afford an opportunity for primary and secondary prevention, both through early detection of childhood disorders and treatment of parental drug dependence and psychopathology.

The authors presented four consecutive case studies in which depressed methadone-maintained patients previously treated with other drugs, such as sertraline, risperidone, and bupropion, and who did not respond and/or suffered various side effects, responded well to nefazodone.

The authors examine the use of anticonvulsants/mood stabilizers to treat patients with substance use disorders. Although there is high comorbidity of bipolar and substance use disorders, there has been little research on the use of these medications to treat bipolar disorders in patients who also have a substance use disorders. However, symptoms of bipolar disorders, such as irritability and mood lability, may be difficult to distinguish from the effects of acute and chronic substance use; therefore, reliable diagnostic methods will need to be developed. Further, a new, hypothesized syndrome, Explosive Mood Disorder, is described that may be distinct from the bipolar spectrum. It is characterized by childhood onset of temper outbursts and irritable mood that persists into adolescence and adulthood, is connected to marijuana use, and responds to divalproex sodium. The authors review studies of prevalence, comorbidity, family history, longitudinal course, and placebo-controlled trials of anticonvulsant medications to evaluate the validity and treatment implications of this proposed entity.