Franz Moggi

Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: Results from an international multi-center study exploring DSM-IV and DSM-5 criteria

Background Available studies vary in their estimated prevalence of attention deficit/hyperactivity disorder (ADHD) in substance use disorder (SUD) patients, ranging from 2 to 83%. A better understanding of the possible reasons for this variability and the effect of the change from DSM-IV to DSM-5 is needed. Methods A two stage international multi-center, cross-sectional study in 10 countries, among patients form inpatient and outpatient addiction treatment centers for alcohol and/or drug use disorder patients. A total of 3558 treatment seeking SUD patients were screened for adult ADHD. A subsample of 1276 subjects, both screen positive and screen negative patients, participated in a structured diagnostic interview. Results Prevalence of DSM-IV and DSM-5 adult ADHD varied for DSM-IV from 5.4% (CI 95%: 2.4–8.3) for Hungary to 31.3% (CI 95%:25.2–37.5) for Norway and for DSM-5 from 7.6% (CI 95%: 4.1–11.1) for Hungary to 32.6% (CI 95%: 26.4–38.8) for Norway. Using the same assessment procedures in all countries and centers resulted in substantial reduction of the variability in the prevalence of adult ADHD reported in previous studies among SUD patients (2–83%→ 5.4–31.3%). The remaining variability was partly explained by primary substance of abuse and by country (Nordic versus non-Nordic countries). Prevalence estimates for DSM-5 were slightly higher than for DSM-IV. Conclusions Given the generally high prevalence of adult ADHD, all treatment seeking SUD patients should be screened and, after a confirmed diagnosis, treated for ADHD since the literature indicates poor prognoses of SUD in treatment seeking SUD patients with ADHD.

Association between cannabis use and sexual risk behavior among young heterosexual adults

To study the association between cannabis use and frequent sexual risk behavior, we tested the hypothesis of a situational influence of cannabis use in sexual encounters using a combination of global association study and event-level analysis and examined possible mediator variables, including the personality trait of hedonism/risk preference, psychosocial stress, and HIV-related beliefs, using mediation models. The results of a computer-assisted telephone interview of a random sample of 2790 heterosexual men and women aged 16–24 years showed that risky sexual behavior was more frequent in cannabis-using men and women than in non-using persons. The results did not support a situational effect of cannabis intoxication on sexual risk behavior. The more frequent sexual risk behavior among cannabis users was mediated by decreased intentions to use HIV protection, by lower HIV-self-efficacy, and higher risk preference/hedonism. Only among women psychosocial stress was a partial mediator. The findings show that HIV prevention programs for cannabis-using young adults should emphasize the role of person variables instead of situation variables.

Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients

BACKGROUND To detect attention deficit hyperactivity disorder (ADHD) in treatment seeking substance use disorders (SUD) patients, a valid screening instrument is needed. OBJECTIVES To test the performance of the Adult ADHD Self-Report Scale V 1.1(ASRS) for adult ADHD in an international sample of treatment seeking SUD patients for DSM-IV-TR; for the proposed DSM-5 criteria; in different subpopulations, at intake and 1-2 weeks after intake; using different scoring algorithms; and different externalizing disorders as external criterion (including adult ADHD, bipolar disorder, antisocial and borderline personality disorder). METHODS In 1138 treatment seeking SUD subjects, ASRS performance was determined using diagnoses based on Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID) as gold standard. RESULTS The prevalence of adult ADHD was 13.0% (95% CI: 11.0-15.0%). The overall positive predictive value (PPV) of the ASRS was 0.26 (95% CI: 0.22-0.30), the negative predictive value (NPV) was 0.97 (95% CI: 0.96-0.98). The sensitivity (0.84, 95% CI: 0.76-0.88) and specificity (0.66, 95% CI: 0.63-0.69) measured at admission were similar to the sensitivity (0.88, 95% CI: 0.83-0.93) and specificity (0.67, 95% CI: 0.64-0.70) measured 2 weeks after admission. Sensitivity was similar, but specificity was significantly better in patients with alcohol compared to (illicit) drugs as the primary substance of abuse (0.76 vs. 0.56). ASRS was not a good screener for externalizing disorders other than ADHD. CONCLUSIONS The ASRS is a sensitive screener for identifying possible ADHD cases with very few missed cases among those screening negative in this population.

The International ADHD in Substance Use Disorders Prevalence (IASP) study: Background, methods and study population

Attention deficit/hyperactivity disorder (ADHD) is an increasingly recognized comorbid condition in subjects with substance use disorders (SUDs).

One-Year Follow-Up of Dual Diagnosis Patients Attending a 4-Month Integrated Inpatient Treatment

The purpose of this study was to assess a 4-month inpatient treatment program based on integrated models for patients with substance use and psychiatric disorders (dual diagnosis patients). On admission and at the 1-year follow-up, a consecutive sample of 118 dual diagnosis patients who entered the program were assessed by interview. Eighty-four patients (70.6%) completed the 1-year follow-up interview, reporting less frequent substance use, less severe psychiatric symptoms, a lower rehospitalization rate, and better housing conditions than on admission. Patients diagnosed with a comorbid personality disorder had a better improvement in the frequency of drinking and were less likely to be rehospitalized than patients with schizophrenia or depression. The results suggest that the integrated inpatient program may be a promising treatment approach for dual diagnosis patients. The results await replication in controlled studies that need to include an assessment of outpatient treatment following inpatient programs.

Treatment Outcomes of an Integrated Residential Programme for Patients with Schizophrenia and Substance Use Disorder

Background: About half of all schizophrenic patients have a co-occurring substance use disorder, leading to poorer social and functional outcomes than obtained in non-abusing patients. To improve outcomes, integrated treatments have been designed that address the two conditions simultaneously. Results are, however, conflicting because the available effect studies are hampered by various methodological issues, among which are heterogeneous patient samples. Methods: In this comparative study, two well-described patient samples diagnosed with schizophrenia and co-morbid substance abuse disorders either received an integrated treatment (IDDT) or treatment as usual (TAU). Results: Patients in the IDDT condition showed significant reductions in illicit drug and alcohol use, improvements on all psychiatric symptom domains, reported higher quality of life and improved on social and community functioning. In contrast, patients’ improvements in the TAU group were moderate and limited to a few substance use and psychiatric outcomes. The TAU group had significantly higher dropout rates 6 and 12 months after baseline, suggesting that the IDDT programme was more successful in committing patients. Conclusions: Our results suggest that an integrated approach to schizophrenic patients and co-morbid substance use disorders is superior to standard treatment and may be considered as the treatment of choice for this patient group.

One-year outcome of an integrative inpatient treatment for dual diagnosis patients

The purpose of this study was to evaluate a 4-month dual diagnosis inpatient treatment program that was based on integrative models for patients with substance use and psychiatric disorders. At intake and at 1-year follow-up, dual diagnosis patients (N = 52) were assessed on housing and subsistence level, substance use and psychiatric symptoms. At 1-year follow-up, dual diagnosis patients reported a higher level of housing and subsistence, and less intensive psychiatric symptoms. No change occurred on frequencies of substance use. General improvement may occur even if psychotropic substances are used. Controlled studies are needed on extended inpatient treatment for dual diagnosis patients and outcomes in longer follow-ups.

Depressive symptoms as a predictor of alcohol relapse after residential treatment programs for alcohol use disorder

Alcohol use disorder (AUD) and depressive disorders often co-occur. Findings on the effects of major depressive disorder (MDD) or depressive symptoms on posttreatment alcohol relapse are controversial. The studys aim is to examine the association of MDD and depressive symptoms with treatment outcomes after residential AUD programs. In a naturalistic-prospective, multisite study with 12 residential AUD treatment programs in the German-speaking part of Switzerland, 64 patients with AUD with MDD, 283 patients with AUD with clinically significant depressive symptoms at admission, and 81 patients with AUD with such problems at discharge were compared with patients with AUD only on alcohol use, depressive symptoms, and treatment service utilization. MDD was provisionally identified at admission and definitively defined at discharge. Whereas patients with MDD did not differ from patients with AUD only at 1-year follow-up, patients with AUD with clinically significant depressive symptoms had significantly shorter time-to-first-drink and a lower abstinence rate. These patients also had elevated AUD indices and treatment service utilization for psychiatric disorders. Our results suggest that clinically significant depressive symptoms are a substantial risk factor for relapse so that it may be important to treat them during and after residential AUD treatment programs.

Patients with Substance Use and Personality Disorders: A Comparison of Patient Characteristics, Treatment Process, and Outcomes in Swiss and U.S. Substance Use Disorder Programs

Background: Cross-cultural comparisons may increase our understanding of different models of substance use treatment and help identify consistent associations between patients’ characteristics, treatment conditions, and outcomes. Objectives: The aim of the study was to compare matched samples of substance use disorder (SUD) patients with personality disorders (PD) in Swiss and the United States (U.S.) residential SUD treatment programs and examine the relationship of program characteristics to 1-year outcomes. Methods: A prospective, naturalistic design was used to compare 132 demographically matched Swiss and U.S. male patients drawn from a sample of 10 Swiss and 15 U.S. public treatment programs. Patients completed comparable inventories at admission, discharge, and 1-year follow-up. Results: Compared to Swiss SUD-PD patients, U.S. SUD-PD patients had more severe substance use and psychosocial problems at admission and follow-up. More intensive treatment and a stronger emphasis on patients’ involvement were related to better outcomes for both Swiss and U.S. SUD-PD patients. Conclusion: There may be some cross-cultural consistency in the associations between treatment characteristics and SUD-PD patients’ outcomes. Scientific Significance: Treatment evaluation findings from representative programs in one country may apply elsewhere and contribute to our overall knowledge about how to improve SUD-PD patients’ outcomes.

Is attention deficit/hyperactivity disorder among men associated with initiation or escalation of substance use at 15-month follow-up? A longitudinal study involving young Swiss men

Abstract Background and Aims Young adults with attention deficit/hyperactivity disorder (ADHD) show higher substance use disorder (SUD) prevalence relative to non‐ADHD controls; few longitudinal studies have examined the course of substance use with reference to conduct disorder (CD). We compared initiation and escalation of substance use at 15‐month follow‐up in men screened positive or negative for ADHD (ADHD+ versus ADHD–), controlling for CD presence in early adolescence. Design Participants were recruited during August 2010 and November 2011 from the census of all young men who have to pass mandatory army conscription from three of six Swiss Army recruitment centres. A two‐wave data collection was performed via questionnaires at baseline and 15‐month follow‐up as a part of the longitudinal Cohort Study on Substance Use Risk Factors. Setting Recruitment centres in Lausanne, Windisch and Mels, responsible for 21 cantons in German‐ and French‐speaking areas of Switzerland. Participants Consecutive sample of 5103 male Swiss Army conscripts who provided informed consent and responded to questionnaires at baseline and 15‐month follow‐up. Their mean age was 20.0 (standard deviation = 1.21) years at baseline. Measurements ADHD and CD were assessed using the adult ADHD Self‐Report Scale and the MINI International Neuropsychiatric Interview Plus, respectively, at baseline, and substance use was measured via self‐administered substance use questionnaires at baseline and follow‐up. Findings Compared with the ADHD– group, the ADHD+ group (n = 215, 4.2%) showed heavier baseline substance use and increased likelihood of alcohol (χ2 = 53.96; P < 0.001), tobacco (χ2 = 21.73; P < 0.001) and cannabis use disorders (χ2 = 48.43; P < 0.001). The extent of alcohol, tobacco and cannabis use in the two groups remained stable from baseline to follow‐up (no escalation). The ADHD+ group was more likely to initiate substance use compared with the ADHD– group (higher initiation rates), particularly with amphetamines [odds ratio (OR) = 3.81; 95% confidence interval (CI) = 2.20–6.60; P < 0.001] and non‐medical use of ADHD medication (OR = 4.45; 95% CI = 2.06–9.60; P < 0.001). CD was associated with initiation of substance use but did not mediate the associations between ADHD and substance use, revealing that the impact of ADHD on substance use was independent of CD. Conclusions For men in their early 20s, attention deficit/hyperactivity disorder is a risk factor for continued heavier but not escalating use of alcohol, tobacco and cannabis when already consuming these substances, compared with young men with no ADHD. It is also a risk factor for initiating the use of cannabis, stimulants, hallucinogens and sedatives, independent of conduct disorder in early adolescence.