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Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders
- By N.I. D.A.
- Published 01/15/2007
- Dual Diagnosis
- Unrated
The Influence of Comorbid Major Depression and Substance Use Disorders on Alcohol and Drug Treatment: Results of a National Survey
Bridget F. Grant
INTRODUCTION
The co-occurrence of alcohol use disorders, drug use disorders, and major depression has frequently been reported in alcoholic, drug abuse, and psychiatric patient samples (Allen and Francis 1986; Demilio 1989; El-Guebaly 1990; Ross et al. 1988; Rounsaville et al. 1982).
Significant associations between substance use disorders and major depression have also been found in general population surveys (Regier et al. 1990; Robins et al. 1988; Weissman and Meyers 1980), but the magnitude is much lower than that reported in clinical samples.
This suggests that people with comorbid substance use disorders and major depression may be more likely to seek alcohol or drug treatment than those without such comorbidities.
However, to date, no studies have examined the impact of comorbidity on alcohol or drug treatment in the population of greatest clinical and policy relevance, that is, among those persons with an alcohol use disorder or drug use disorder not found in the treated population.
The purpose of this study was to separately compare the comorbidity status of persons with alcohol and drug use disorders who did or did not seek alcohol or drug treatment, respectively.
Separate comparisons were also examined for major types of treatment facilities, including 12-step group programs and inpatient and outpatient facilities.
METHODS
Sample - The study was based on the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES), a nationwide household survey sponsored by the National Institute on Alcohol Abuse and Alcoholism (Grant et al. 1992). Field work for the study was conducted by the 5 Bureau of the Census. During the survey, direct face-to-face interviews were conducted with 42,862 respondents, 18 years of age and older, in the contiguous United States and the District of Columbia.
The household response rate for the NLAES was 91.9 percent, and the person response rate was 97.4 percent. The NLAES featured a complex multistage design (Massey et al. 1989). Primary sampling units (PSUs) were stratified according to sociodemographic criteria and were selected with probabilities proportional to size.
Approximately 2,000 PSUs comprised the 1992 NLAES sample, 52 of which were self-representing—that is, selected with certainty. Within PSUs, geographically defined secondary sampling units, referred to as segments, were selected systematically for each sample.
Oversampling of the black population was accomplished at this stage of sampling in order to have adequate numbers for analytic purposes. Segments were then divided into clusters of approximately four to eight housing units, and all occupied housing units were included in the NLAES.
Within each household, one randomly selected respondent, 18 years of age or older, was selected to participate in the survey. Oversampling of young adults, 18 to 29 years of age, was accomplished at this stage of the sample selection to include a greater representation of this heavier substance-abusing population subgroup. This subgroup of young adults was sampled at a ratio of 2.25 percent to 1.00.
Diagnostic Assessment
The survey questionnaire, the Alcohol Use Disorders and Associated Disabilities Interview Schedule (AUDADIS) (Grant and Hasin 1992), included an extensive list of symptom questions that operationalized the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) (American Psychiatric Association 1994) criteria for alcohol/drug use disorders and major depression.
These questions are described in detail elsewhere (Grant et al. 1994). Past year DSM-IV drug-specific diagnoses of abuse and dependence were first derived separately for alcohol, sedatives, tranquilizers, opioids (other than heroin), amphetamines, cocaine (and crack cocaine), cannabis (and THC and hashish), heroin, methadone, and hallucinogens.
A composite measure of any of these drug use disorders (except alcohol) was then constructed.
Consistent with the DSM-IV, an AUDADIS diagnosis of alcohol or drug abuse required that a person exhibit a maladaptive pattern of substance use leading to clinically significant impairment or distress, as demonstrated by at least one of the following in any 1 year: (1) continuing to use despite a social or interpersonal problem caused or exacerbated by the effects of use, (2) recurrent use in situations in which substance use is physically hazardous, (3) recurrent use resulting in a failure to fulfill major role obligations, or (4) recurrent substance-related legal problems.
An AUDADIS diagnosis of substance dependence required that a person meet at least three of seven criteria defined for dependence in any 1 year, including: (1) tolerance; (2) avoidance of withdrawal; (3) persistent desire or unsuccessful attempts to cut down or stop using; (4) spending much time obtaining a drug, using it, or recovering from its effects; (5) giving up or reducing occupational, social, or recreational activities in favor of use; (6) impaired control over use; and (7) continuing to use despite a physical or psychological problem caused or exacerbated by use.
Diagnoses of alcohol and drug abuse and dependence also satisfied the clustering or duration criteria of the DSM-IV. The duration criteria of the DSM-IV include the requirement for a clustering of symptoms within any 1-year period, in addition to associating duration qualifiers with certain abuse and dependence symptoms.
The duration qualifiers are defined as the repetitiveness with which symptoms must occur in order to be counted as positive towards a diagnosis. They are represented by the terms "recurrent," "often," and "persistent" appearing in the description of the diagnostic criteria.
Consistent with the DSM-IV, the AUDADIS diagnosis of major depression required the presence of at least five depressive symptoms (inclusive of depressed mood or loss of pleasure and interest) nearly every day for most of the day during any 2-week period.
Social and/or occupational dysfunction must also have been present during the disturbance, and episodes of major depression exclusively due to bereavement or physical illness were ruled out. The reliabilities of the diagnoses of DSM-IV alcohol and drug use disorders and major depression were 0.73, 0.80, and 0.65, as determined from an independent test-retest study conducted in a general population sample (Grant et al. 1995).
Alcohol and Drug Treatment Respondents in the survey were asked if, during the past year, they had gone anywhere or seen anyone for problems related to their drinking.
To more completely capture the entire alcohol help-seeking population, respondents were specifically instructed to indicate any help they had received for their drinking, including help for combined alcohol and drug use if alcohol was the major problem for which they sought help.
Alcohol treatment sources were defined broadly and respondents were asked to indicate separately whether they sought help from 23 different treatment sources: inpatient alcohol and/or rehabilitation programs and inpatient wards of general or psychiatric hospitals; outpatient clinics and alcohol and/or drug detoxification units; 12-step groups including Alcoholics Anonymous, Narcotics or Cocaine Anonymous, or Alanon; social services; and various health professionals such as psychiatrists, psychologists, social workers, and the clergy.
Respondents receiving help from any of these sources during the past year constituted the alcohol treatment group examined in this study. The drug treatment measure included the same range of treatment sources as described for alcohol, but information was solicited from respondents regarding help they had received for a drug problem, including help for combined drug and alcohol use if use of a drug or drugs was the major problem for which they sought help.
~~~
Continued on source document:
NIDA Research Monograph, Number 172
Bridget F. Grant
INTRODUCTION
The co-occurrence of alcohol use disorders, drug use disorders, and major depression has frequently been reported in alcoholic, drug abuse, and psychiatric patient samples (Allen and Francis 1986; Demilio 1989; El-Guebaly 1990; Ross et al. 1988; Rounsaville et al. 1982).
Significant associations between substance use disorders and major depression have also been found in general population surveys (Regier et al. 1990; Robins et al. 1988; Weissman and Meyers 1980), but the magnitude is much lower than that reported in clinical samples.
This suggests that people with comorbid substance use disorders and major depression may be more likely to seek alcohol or drug treatment than those without such comorbidities.
However, to date, no studies have examined the impact of comorbidity on alcohol or drug treatment in the population of greatest clinical and policy relevance, that is, among those persons with an alcohol use disorder or drug use disorder not found in the treated population.
The purpose of this study was to separately compare the comorbidity status of persons with alcohol and drug use disorders who did or did not seek alcohol or drug treatment, respectively.
Separate comparisons were also examined for major types of treatment facilities, including 12-step group programs and inpatient and outpatient facilities.
METHODS
Sample - The study was based on the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES), a nationwide household survey sponsored by the National Institute on Alcohol Abuse and Alcoholism (Grant et al. 1992). Field work for the study was conducted by the 5 Bureau of the Census. During the survey, direct face-to-face interviews were conducted with 42,862 respondents, 18 years of age and older, in the contiguous United States and the District of Columbia.
The household response rate for the NLAES was 91.9 percent, and the person response rate was 97.4 percent. The NLAES featured a complex multistage design (Massey et al. 1989). Primary sampling units (PSUs) were stratified according to sociodemographic criteria and were selected with probabilities proportional to size.
Approximately 2,000 PSUs comprised the 1992 NLAES sample, 52 of which were self-representing—that is, selected with certainty. Within PSUs, geographically defined secondary sampling units, referred to as segments, were selected systematically for each sample.
Oversampling of the black population was accomplished at this stage of sampling in order to have adequate numbers for analytic purposes. Segments were then divided into clusters of approximately four to eight housing units, and all occupied housing units were included in the NLAES.
Within each household, one randomly selected respondent, 18 years of age or older, was selected to participate in the survey. Oversampling of young adults, 18 to 29 years of age, was accomplished at this stage of the sample selection to include a greater representation of this heavier substance-abusing population subgroup. This subgroup of young adults was sampled at a ratio of 2.25 percent to 1.00.
Diagnostic Assessment
The survey questionnaire, the Alcohol Use Disorders and Associated Disabilities Interview Schedule (AUDADIS) (Grant and Hasin 1992), included an extensive list of symptom questions that operationalized the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) (American Psychiatric Association 1994) criteria for alcohol/drug use disorders and major depression.
These questions are described in detail elsewhere (Grant et al. 1994). Past year DSM-IV drug-specific diagnoses of abuse and dependence were first derived separately for alcohol, sedatives, tranquilizers, opioids (other than heroin), amphetamines, cocaine (and crack cocaine), cannabis (and THC and hashish), heroin, methadone, and hallucinogens.
A composite measure of any of these drug use disorders (except alcohol) was then constructed.
Consistent with the DSM-IV, an AUDADIS diagnosis of alcohol or drug abuse required that a person exhibit a maladaptive pattern of substance use leading to clinically significant impairment or distress, as demonstrated by at least one of the following in any 1 year: (1) continuing to use despite a social or interpersonal problem caused or exacerbated by the effects of use, (2) recurrent use in situations in which substance use is physically hazardous, (3) recurrent use resulting in a failure to fulfill major role obligations, or (4) recurrent substance-related legal problems.
An AUDADIS diagnosis of substance dependence required that a person meet at least three of seven criteria defined for dependence in any 1 year, including: (1) tolerance; (2) avoidance of withdrawal; (3) persistent desire or unsuccessful attempts to cut down or stop using; (4) spending much time obtaining a drug, using it, or recovering from its effects; (5) giving up or reducing occupational, social, or recreational activities in favor of use; (6) impaired control over use; and (7) continuing to use despite a physical or psychological problem caused or exacerbated by use.
Diagnoses of alcohol and drug abuse and dependence also satisfied the clustering or duration criteria of the DSM-IV. The duration criteria of the DSM-IV include the requirement for a clustering of symptoms within any 1-year period, in addition to associating duration qualifiers with certain abuse and dependence symptoms.
The duration qualifiers are defined as the repetitiveness with which symptoms must occur in order to be counted as positive towards a diagnosis. They are represented by the terms "recurrent," "often," and "persistent" appearing in the description of the diagnostic criteria.
Consistent with the DSM-IV, the AUDADIS diagnosis of major depression required the presence of at least five depressive symptoms (inclusive of depressed mood or loss of pleasure and interest) nearly every day for most of the day during any 2-week period.
Social and/or occupational dysfunction must also have been present during the disturbance, and episodes of major depression exclusively due to bereavement or physical illness were ruled out. The reliabilities of the diagnoses of DSM-IV alcohol and drug use disorders and major depression were 0.73, 0.80, and 0.65, as determined from an independent test-retest study conducted in a general population sample (Grant et al. 1995).
Alcohol and Drug Treatment Respondents in the survey were asked if, during the past year, they had gone anywhere or seen anyone for problems related to their drinking.
To more completely capture the entire alcohol help-seeking population, respondents were specifically instructed to indicate any help they had received for their drinking, including help for combined alcohol and drug use if alcohol was the major problem for which they sought help.
Alcohol treatment sources were defined broadly and respondents were asked to indicate separately whether they sought help from 23 different treatment sources: inpatient alcohol and/or rehabilitation programs and inpatient wards of general or psychiatric hospitals; outpatient clinics and alcohol and/or drug detoxification units; 12-step groups including Alcoholics Anonymous, Narcotics or Cocaine Anonymous, or Alanon; social services; and various health professionals such as psychiatrists, psychologists, social workers, and the clergy.
Respondents receiving help from any of these sources during the past year constituted the alcohol treatment group examined in this study. The drug treatment measure included the same range of treatment sources as described for alcohol, but information was solicited from respondents regarding help they had received for a drug problem, including help for combined drug and alcohol use if use of a drug or drugs was the major problem for which they sought help.
~~~
Continued on source document:
NIDA Research Monograph, Number 172
