Dara A. Charney

The Impact of Depression on the Outcome of Addictions Treatment

The objectives of this study were to examine the prevalence and presentation of depression among patients with substance use disorders, and to explore the relationship between depression and the outcome of addictions treatment. Seventy-five patients were consecutively recruited upon entering addictions treatment, and were assessed by clinical and semi-structured interviews, Hamilton Rating Scale for Depression, Global Assessment Scale, and Beck Depression Inventory. At intake, 22.4% of patients had primary depressive disorders, 8.4% had substance-induced depressions, and 5.6% had mixed features of primary and substance-induced depressions. Female and alcoholic patients were more likely to suffer from both primary and substance-induced depressions. At 3 months, 93.3% of patients were reinterviewed. Depressed patients had longer duration of abstinence and greater decreases in symptomatology. Patients with substance-induced depression achieved almost complete discontinuation of primary substance use. Depression had a significant impact on addictions treatment outcome, but many important predictors of outcome have not yet been identified.

Early recovery from alcohol dependence: Factors that promote or impede abstinence

The objectives of this prospective follow-up study were to identify factors that promote or impede the early recovery process and to examine whether drinking status at 4 weeks predicts later abstinence. Patients with alcohol use disorders were assessed by clinical and semistructured interviews upon entering addiction treatment (N = 175) and were followed up biweekly to monitor their alcohol use. During the first 4 weeks of treatment, 57% (n = 100) of patients slipped or relapsed on alcohol, whereas 43% (n = 75) were fully abstinent. Patients who slipped or relapsed were more likely to report nondependent use of a secondary substance, meet criteria for a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis II Cluster B personality disorder, have a higher level of impulsivity, and have more severe social problems at intake. The final logistic regression model accounted for 37% of the variance in drinking status. Patients who slipped or relapsed early in treatment were likely to continue to struggle to maintain abstinence at 12 weeks.

Alcohol consumption and major depression in the Canadian population.

Objective: Various clinical studies have documented associations between alcohol consumption and depressive disorders. In some circumstances, alcohol ingestion may cause or worsen depression, whereas in other circumstances the direction of causal effect may be reversed. The objective of this study was to evaluate associations between alcohol consumption and major depression in the Canadian population. Method: Data from the Canadian National Population Health Survey (NPHS) were analyzed. This survey, conducted by Statistics Canada in 1994, used a probability sample of 17 626 subjects. The NPHS included measures of alcohol ingestion and a diagnostic screen for major depression (Composite International Diagnostic Interview [CIDI] Short Form). Results: Subjects reporting any drinking in the year preceding the interview were more likely to have experienced an episode of major depression during that time than subjects reporting no drinking. Subjects reporting maximal ingestions of 5 or more drinks (and especially 10 or more drinks) on at least 1 occasion during the preceding year were also at greater risk of major depression than nondrinking subjects or subjects reporting smaller maximal ingestions. Neither the average amount consumed daily nor the frequency of drinking was associated with major depression. Conclusions: In the general population, there is no simple relationship between the quantity or frequency of alcohol consumption and the prevalence of major depression. Any drinking and maximal consumption on I occasion, however, are related to the prevalence of major depression. Further research is needed to delineate causal mechanisms so that clinical and public-health interventions can be formulated.

Personality disorders among alcoholic outpatients: prevalence and course in treatment.

Objective: To determine the prevalence of concurrent personality disorders (PDs) among alcoholic men and women seeking outpatient treatment, and to examine their effect on the course of alcohol treatment. Method: Patients with alcohol use disorders (n = 165) were assessed by clinical and semi-structured interviews, as well as self-report scales, to measure levels of psychological distress, impulsivity, social functioning, and addiction severity at treatment intake. PD diagnoses were assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Personality Disorder (SCID-II). Course in treatment was monitored prospectively for 12 weeks. Results: Using the results of the SCID-II (n = 138), the sample was divided into 3 groups—that is, no PD 41% (n = 57), Cluster B PD 32% (n = 44), and other PD 27% (n = 37). The 3 groups did not differ in their alcohol use severity at intake. However, the Cluster B PD group achieved alcohol milestones at a younger age. Subjects with a PD had more severe psychological and social problems at intake. The Cluster B PD group showed significantly higher levels of impulsivity at intake, greater likelihood of early treatment dropout, and quicker times to first slip and to relapse. Conclusions: This study supports the high prevalence of concurrent PDs, particularly Cluster B PDs, among treatment-seeking alcoholics. The relation between observed high levels of impulsivity and worse course in early alcohol treatment among people with a Cluster B PD merits further investigation.

Alterations in Brain Serotonin Synthesis in Male Alcoholics Measured Using Positron Emission Tomography

BACKGROUND A consistent association between low endogenous 5HT function and high alcohol preference has been observed, and a number of serotonergic manipulations (uptake blockers, agonists) alter alcohol consumption in animals and humans. Studies have also shown an inverse relationship between alcohol use and cerebrospinal fluid levels of serotonin metabolites, suggesting that chronic alcohol consumption produces alterations in serotonin synthesis or release. METHODS The objective of the study was to characterize regional brain serotonin synthesis in nondepressed chronic alcoholics at treatment entry in comparison to normal nonalcoholic controls using PET and the tracer alpha-[(11)C]-methyl-L-tryptophan. RESULTS Comparisons of the alcoholics and controls by SPM found that there were significant differences in the rate of serotonin synthesis between groups. Serotonin synthesis was significantly lower among alcoholics in Brodmann Area (BA) 9, 10, and 32. However, serotonin synthesis among the alcoholics group was significantly higher than controls at BA19 in the occipital lobe and around the transverse temporal convolution in the left superior temporal gyrus (BA41). In addition, there were correlations between regional serotonin synthesis and a quantity-frequency measure of alcohol consumption. Regions showing a significant negative correlation with QF included the bilateral rectus gyri (BA11) in the orbitofrontal area, the bilateral medial frontal area (BA6), and the right amygdala. CONCLUSIONS Current alcoholism is associated with serotonergic abnormalities in brain regions that are known to be involved in planning, judgment, self-control, and emotional regulation.

An Abstinence-Oriented Program for Substance Use Disorders: Poorer Outcome Associated With Opiate Dependence

Objectives: To evaluate the characteristics of patients with various substance-related disorders, and to examine rates of retention in treatment. Methods: We assessed the demographic characteristics, substance abuse, and psychological distress of 239 men and women at admission. Six-month performance was evaluated, using as criteria length of stay in treatment, abstinence, attendance in therapy sessions, and completion status at discharge. Results: Moderate to severe psychological distress was observed among these individuals. Higher levels of depression were found among women and in individuals with alcohol and sedative use disorders. The primary drug of abuse, frequency of use, and reason for entering treatment were the most significant predictors of retention. Conclusions: Opiate-addicted clients had the worst prognosis and treatment profiles. Further research is needed to identify factors that would optimize treatment for opiate dependence.

NEUROPSYCHOLOGICAL FUNCTIONING IN SUBSTANCE-DEPENDENT PATIENTS

The present study examined neurocognitive functioning in groups of individuals addicted to various psychoactive substances. One hundred ten patients admitted to treatment for substance misuse were assessed using a semistructured clinical interview, the Beck Depression Inventory, the Symptom CheckList-90, the Trail Making A and B tests, and the Shipley Institute of Living Scale. Results revealed that at intake, alcohol- and benzodiazepine-addicted clients exhibited higher levels of cognitive impairment and psychological distress than patients dependent on other drugs. Regression analysis showed that the Shipley vocabulary raw score was a significant predictor of length of stay in treatment.

Poorer Drinking Outcomes with Citalopram Treatment for Alcohol Dependence: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND Previous research on the use of selective serotonin reuptake inhibitors (SSRIs) as a treatment for alcohol dependence has yielded mixed results. Depression has been shown to be a predictor of relapse and poor outcome following treatment, and it has been hypothesized that SSRIs would be beneficial in reducing drinking in depressed alcohol-dependent individuals. This randomized, double-blind, placebo-controlled trial was designed to test the effects of citalopram on treatment outcomes among alcohol-dependent individuals with and without depression. METHODS Two hundred and sixty-five patients meeting criteria for a DSM-IV diagnosis of alcohol abuse or dependence were randomly assigned to receive placebo or citalopram 20 mg per day for the first week, followed by 40 mg per day from weeks 2 through 12. All patients received a standard course of treatment consisting of weekly individual and group psychotherapy. Participants were reassessed at 12 weeks, including dropouts from both treatment groups to determine rates of abstinence, changes in alcohol use, addiction severity, depressive symptoms, and psychiatric status. RESULTS Citalopram provided no advantage over placebo in terms of treatment outcomes, and for some measures, citalopram produced poorer outcomes. Patients in the citalopram group had a higher number of heavy drinking days throughout the trial, and smaller changes in frequency and amount of alcohol consumption at 12 weeks. There was no influence of depression severity on outcomes in either medication group. Survival analyses also indicated no differences between depressed and nondepressed patients in the citalopram group for time to first slip or relapse. A diagnosis of personality disorder was associated with poorer treatment responses overall, regardless of treatment condition. CONCLUSIONS This trial does not support the use of citalopram in the treatment of alcohol dependence. The results suggest that the use of SSRIs among depressed and nondepressed alcohol-dependent individuals early in recovery, prior to the onset of abstinence, may be contraindicated.

Teaching on gender-related issues; a survey of psychiatry faculty and residents

A survey was distributed to 299 members of the McGill Department of Psychiatry regarding the teaching of gender‐related issues. The response rate was 62·5%. The majority of respondents indicated that they were moderately or very knowledgeable about, and moderately or very interested in gender issues. Current teaching was rated as less than adequate, while future teaching was rated as very important. Women rated personal interest and importance of future teaching higher than men, but rated adequacy of current teaching lower. Residents rated personal interest higher than certified psychiatrists, but rated self‐assessed knowledge lower, and tended to rate adequacy of current teaching lower.

From policy to practice: implementing frontline community health services for substance dependence–study protocol

BackgroundSubstance abuse is a worldwide public health concern. Extensive scientific research has shown that screening and brief interventions for substance use disorders administered in primary care provide substantial benefit at relatively low cost. Frontline health clinicians are well placed to detect and treat patients with substance use disorders. Despite effectiveness shown in research, there are many factors that impact the implementation of these practices in real-world clinical practice. Recently, the Ministry of Health and Social Services in Quebec, Canada, issued two policy documents aimed at introducing screening and early intervention for substance abuse into frontline healthcare clinics in Quebec. The current research protocol was developed in order to study the process of implementation of evidence-based addiction treatment practices at three primary care clinics in Montreal (Phase 1). In addition, the research protocol was designed to examine the efficacy of overall policy implementation, including barriers and facilitators to addictions program development throughout Quebec (Phase 2).Methods/DesignPhase 1 will provide an in-depth case study of knowledge translation and implementation. The study protocol will utilize an integrated knowledge translation strategy to build collaborative mechanisms for knowledge exchange between researchers, addiction specialists, and frontline practitioners (guided by the principles of participatory-action research), and directly examine the process of knowledge uptake and barriers to transfer using both qualitative and quantitative methodologies. Evaluation will involve multiple measures, time points and domains; program uptake and effectiveness will be determined by changes in healthcare service delivery, sustainability and outcomes. In Phase 2, qualitative methods will be utilized to examine the contextual facilitators and barriers that frontline organizations face in implementing services for substance dependence. Phase 2 will provide the first study exploring the wide-scale implementation of frontline services for substance dependence in the province of Quebec and yield needed information about how to effectively implement mandated policies into clinical practice and impact public health.DiscussionFindings from this research program will contribute to the understanding of factors associated with implementation of frontline services for substance dependence and help to inform future policy and organizational support for the implementation of evidence-based practices.