Gail Gilchrist

Psychiatric comorbidity in illicit drug users: substance-induced versus independent disorders

BACKGROUND Few studies have differentiated between independent and substance-induced psychiatric disorders. In this study we determine the risks associated with independent and substance-induced psychiatric disorders among a sample of 629 illicit drug users recruited from treatment and out of treatment settings. METHODS Secondary analysis of five cross-sectional studies conducted during 2000-2006. Independent and substance-induced DSM-IV psychiatric diagnoses were assessed using the Psychiatric Research Interview for Substance and Mental Disorders. RESULTS Lifetime prevalence of Axis I disorders other than substance use disorder (SUD) was 41.8%, with independent major depression being the most prevalent (17%). Lifetime prevalence of antisocial or borderline personality disorders was 22.9%. In multinominal logistic regression analysis (SUD only as the reference group), being female (OR 2.45; 95% CI 1.59, 3.77) and having lifetime borderline personality disorder (OR 2.45; 95% CI 1.31, 4.59) remained significant variables in the group with independent disorders. In the group with substance-induced disorders, being recruited from an out of treatment setting (OR 3.50; 95% CI 1.54, 7.97), being female (OR 2.38; 95% CI 1.24, 4.59) and the number of SUD (OR 1.31; 95% CI 1.10, 1.57) remained significant in the model. These variables were also significant in the group with both substance-induced and independent disorders, together with borderline personality disorder (OR 2.53; 95% CI 1.03, 6.27). CONCLUSIONS Illicit drug users show high prevalence of co-occurrence of mainly independent mood and anxiety psychiatric disorders. Being female, recruited from an out of treatment setting and the number of SUD, are risk factors for substance-induced disorders.

Observational studies of depression in primary care: what do we know?

BackgroundWe undertook a systematic review of observational studies of depression in primary care to determine 1) the nature and scope of the published studies 2) the methodological quality of the studies; 3) the identified recovery and risk factors for persistent depression and 3) the treatment and health service use patterns among patients.MethodsSearches were conducted in MEDLINE, CINAHL and PsycINFO using combinations of topic and keywords, and Medical Subject Headings in MEDLINE, Headings in CINAHL and descriptors in PsycINFO. Searches were limited to adult populations and articles published in English during 1985–2006.Results40 articles from 17 observational cohort studies were identified, most were undertaken in the US or Europe. Studies varied widely in aims and methods making it difficult to meaningfully compare the results. Methodological limitations were common including: selection bias of patients and physicians; small sample sizes (range 35–108 patients at baseline and 20–59 patients at follow-up); and short follow-up times limiting the extent to which these studies can be used to inform our understanding of recovery and relapse among primary care patients with depression. Risk factors for the persistence of depression identified in this review were: severity and chronicity of the depressive episode, the presence of suicidal thoughts, antidepressant use, poorer self-reported quality of life, lower self-reported social support, experiencing key life events, lower education level and unemployment.ConclusionDespite the growing interest in depression being managed as a chronic illness, this review identified only 17 observational studies of depression in primary care, most of which have included small sample sizes and been relatively short-term. Future research should be large enough to investigate risk factors for chronicity and relapse, and should be conducted over a longer time frame.

Staff regard towards working with substance users: a European multi-centre study

AIMS To compare regard for working with different patient groups (including substance users) among different professional groups in different health-care settings in eight European countries. DESIGN A multi-centre, cross-sectional comparative study. SETTING Primary care, general psychiatry and specialist addiction services in Bulgaria, Greece, Italy, Poland, Scotland, Slovakia, Slovenia and Spain. PARTICIPANTS A multi-disciplinary convenience sample of 866 professionals (physicians, psychiatrists, psychologists, nurses and social workers) from 253 services. MEASUREMENTS The Medical Condition Regard Scale measured regard for working with different patient groups. Multi-factor between-subjects analysis of variance determined the factors associated with regard for each condition by country and all countries. FINDINGS Regard for working with alcohol (mean score alcohol: 45.35, 95% CI 44.76, 45.95) and drug users (mean score drugs: 43.67, 95% CI 42.98, 44.36) was consistently lower than for other patient groups (mean score diabetes: 50.19, 95% CI 49.71, 50.66; mean score depression: 51.34, 95% CI 50.89, 51.79) across all countries participating in the study, particularly among staff from primary care compared to general psychiatry or specialist addiction services (P<0.001). After controlling for sex of staff, profession and duration of time working in profession, treatment entry point and country remained the only statistically significant variables associated with regard for working with alcohol and drug users. CONCLUSIONS Health professionals appear to ascribe lower status to working with substance users than helping other patient groups, particularly in primary care; the effect is larger in some countries than others.

A trajectory-based approach to understand the factors associated with persistent depressive symptoms in primary care

BACKGROUND Depression screening in primary care yields high numbers. Knowledge of how depressive symptoms change over time is limited, making decisions about type, intensity, frequency and length of treatment and follow-up difficult. This study is aimed to identify depressive symptom trajectories and associated socio-demographic, co-morbidity, health service use and treatment factors to inform clinical care. METHODS 789 people scoring 16 or more on the CES-D recruited from 30 randomly selected Australian family practices. Depressive symptoms are measured using PHQ-9 at 3, 6, 9 and 12 months. RESULTS Growth mixture modelling identified a five-class trajectory model as the best fitting (lowest Bayesian Information Criterion): three groups were static (mild (n=532), moderate (n=138) and severe (n=69)) and two were dynamic (decreasing severity (n=32) and increasing severity (n=18)). The mild symptom trajectory was the most common (n=532). The severe symptom trajectory group (n=69) differed significantly from the mild symptom trajectory group on most variables. The severe and moderate groups were characterised by high levels of disadvantage, abuse, morbidity and disability. Decreasing and increasing severity trajectory classes were similar on most variables. LIMITATIONS Adult only cohort, self-report measures. CONCLUSIONS Most symptom trajectories remained static, suggesting that depression, as it presents in primary care, is not always an episodic disorder. The findings indicate future directions for building prognostic models to distinguish those who are likely to have a mild course from those who are likely to follow more severe trajectories. Determining appropriate clinical responses based upon a likely depression course requires further research.

The efficacy of cognitive behavioural therapy and advocacy interventions for women who have experienced intimate partner violence: A systematic review and meta-analysis

Abstract Objective. To determine the efficacy of Advocacy and Cognitive Behavioural Therapy interventions (CBT) in reducing physical, psychological, sexual, or any intimate partner violence (IPV). Methods. A systematic review and meta-analysis were conducted using randomized control trials (RCTs) published in MEDLINE, PsycINFO, Scopus, Cochrane, and Clinical trials. The occurrence of physical, psychological, sexual, and/or any IPV measured efficacy. Results. Twelve RCTs involving 2666 participants were included. Advocacy interventions resulted in significant reductions in physical (standardized mean difference (SMD) –0.13; 95% confidence interval (CI) –0.25, –0.00) and psychological (SMD –0.19; 95% CI –0.32, –0.05) but not in sexual (SMD –0.20; 95% CI –0.43, 0.02) or any IPV (SMD –0.32; 95% CI –0.69, 0.04). CBT interventions showed a significant reduction in physical (SMD –0.79; 95% CI –1.26, –0.33) and psychological (SMD –0.80; 95% CI –1.25, –0.36) but not sexual (SMD –0.35; 95% CI –1.73, 1.03) or any IPV (SMD 0.09; 95% CI –0.05, 0.23). Conclusions. Both advocacy and CBT interventions reduced physical and psychological IPV but not sexual or any IPV. Limitations include the low number of studies and the heterogeneity of interventions.

Psychiatric, Behavioural and Social Risk Factors for HIV Infection Among Female Drug Users

Female drug users report greater psychopathology and risk behaviours than male drug users, putting them at greater risk for HIV. This mixed-methods study determined psychiatric, behavioural and social risk factors for HIV among 118 female drug users (27% (32/118) were HIV seropositive) in Barcelona. DSM-IV disorders were assessed using the Spanish Psychiatric Research Interview for Substance and Mental Disorders. 30 participants were interviewed in-depth. In stepwise multiple backward logistic regression, ever injected with a used syringe, antisocial personality disorder, had an HIV seropositive sexual partner and substance-induced major depressive disorder were associated with HIV seropositivity. Qualitative findings illustrate the complex ways in which psychiatric disorders and male drug-using partners interact with these risk factors. Interventions should address all aspects of female drug users’ lives to reduce HIV.ResumenLas mujeres consumidoras de drogas presentan más psicopatología y conductas de riesgo que los consumidores, exponiéndolas a un riesgo mayor de contraer la infección por el VIH. El objetivo del presente estudio fue evaluar, mediante metodología mixta, los factores de riesgo psiquiátricos, comportamentales y sociales para la infección por el VIH en 118 mujeres consumidoras de drogas (27% (32/118) seropositivas para el VIH) en Barcelona. Los trastornos psiquiátricos (según criterios DSM-IV) se evaluaron mediante la versión española de la Psychiatric Research Interview for Substance and Mental Disorders. Se entrevistaron a 30 mujeres en profundidad. En la regresión logística, los factores que se asociaron a la infección por el VIH fueron la inyección con jeringuillas usadas previamente, tener el trastorno de personalidad antisocial, una pareja sexual con infección por el VIH y tener una depresión mayor inducida por sustancias. Los análisis cualitativos ilustraron la complejidad con que los trastornos psiquiátricos y las parejas consumidoras interactúan con estos factores de riesgo. Las intervenciones diseñadas para reducir la infección del VIH deberían abordar diferentes aspectos de la vida de las mujeres usuarias de drogas.

Drug using mothers: factors associated with retaining care of their children

INTRODUCTION AND AIMS Research suggests that upwards of 50% of drug users do not live with their children, yet little is known about these childrens living arrangements or the variables associated with mothers retaining care of their children. DESIGN AND METHODS This cross-sectional study examined the number of pregnancies and children born to female drug users receiving and not receiving treatment, the living arrangements of their children and the variables associated with not living with their children. RESULTS Data on 185 mothers from a study on psychiatric morbidity among drug users in Glasgow, Scotland were analysed. Participants had given birth to 327 children, 44% (132/297) of children were living with their mother; 26% (78/297) were being cared for by a family member and 20% (59/297) were in local authority care or had been adopted. 49% (87/179) of participants did not live with any of their children. Stepwise multiple forward logistic regression found that current depressive symptoms [odds ratios (OR) 3.90, 95% confidence intervals (CI) 1.78-8.55], lifetime involvement in prostitution (OR 3.12, 95% CI 1.41-6.93), lifetime history of homeless (OR 2.96, 95% CI 1.13-6.39), living with a drug user (OR 2.71, 95% CI 1.30-5.65) and ever being incarcerated (OR 2.47, 95% CI 1.17-5.21) were associated with participants not living with any of their children versus living with at least one of their children. DISCUSSION AND CONCLUSIONS Access to drug treatment, mental health treatment and parent craft education should be enhanced for female drug users to assist them retain care of their children where possible.

The association between intimate partner violence, alcohol and depression in family practice

BackgroundDepressive symptoms, intimate partner violence and hazardous drinking are common among patients attending general practice. Despite the high prevalence of these three problems; the relationship between them remains relatively unexplored.MethodsThis paper explores the association between depressive symptoms, ever being afraid of a partner and hazardous drinking using cross-sectional screening data from 7667 randomly selected patients from a large primary care cohort study of 30 metropolitan and rural general practices in Victoria, Australia. The screening postal survey included the Center for Epidemiological Studies Depression Scale, the Fast Alcohol Screening Test and a screening question from the Composite Abuse Scale on ever being afraid of any intimate partner.Results23.9% met criteria for depressive symptoms. A higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0) and a lower proportion of females (12%) than males (25%) were hazardous drinkers (OR 0.4; 95%CI 0.4 to 0.5); and a higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0). Men and women who had ever been afraid of a partner or who were hazardous drinkers had on average higher depressive symptom scores than those who had never been afraid or who were not hazardous drinkers. There was a stronger association between depressive symptoms and ever been afraid of a partner compared to hazardous drinking for both males (ever afraid of partner; Diff 6.87; 95% CI 5.42, 8.33; p < 0.001 vs. hazardous drinking in last year; Diff 1.07, 95% CI 0.21, 1.94; p = 0.015) and females (ever afraid of partner; Diff 5.26; 95% CI 4.55, 5.97; p < 0.001 vs. hazardous drinking in last year; Diff 2.23, 95% CI 1.35, 3.11; p < 0.001), even after adjusting for age group, income, employment status, marital status, living alone and education level.ConclusionsStrategies to assist primary care doctors to recognise and manage intimate partner violence and hazardous drinking in patients with depression may lead to better outcomes from management of depression in primary care.

Feasibility Randomized Controlled Trial of Cognitive and Behavioral Interventions for Depression Symptoms in Patients Accessing Drug and Alcohol Treatment

Depressed mood often co-exists with frequent drug and alcohol use. This trial examined the feasibility of screening, recruitment, randomization and engagement of drug and alcohol users in psychological interventions for depression symptoms. A total of 50 patients involved in community drugs and alcohol treatment (CDAT) were randomly allocated to behavioral activation delivered by psychological therapists (n = 23) or to cognitive behavioral therapy based self-help introduced by CDAT workers (n = 27). We examined recruitment and engagement rates, as well as changes in depression (PHQ-9) symptoms and changes in percent days abstinent (PDA within last month) at 24 weeks follow-up. The ratio of screened to recruited participants was 4 to 1, and the randomization schedule successfully generated 2 groups with comparable characteristics. Follow-up was possible with 78% of participants post-treatment. Overall engagement in psychological interventions was low; only 42% of randomized participants attended at least 1 therapy session. Patients offered therapy appointments co-located in CDAT clinics were more likely to engage with treatment (odds ratio = 7.14, p = .04) compared to those offered appointments in community psychological care clinics. Intention-to-treat analyses indicated no significant between-group differences at follow-up in mean PHQ-9 change scores (p = .59) or in PDA (p = .08). Overall, it was feasible to conduct a pragmatic trial within busy CDAT services, maximizing external validity of study results. Moderate and comparable improvements in depression symptoms over time were observed for participants in both treatment groups.

Predictors of neurotic symptom severity among female drug users in Glasgow, Scotland

Aims: The prevalence and predictors of neurotic symptom severity among 266 female drug users recruited from three services in Glasgow, Scotland, is described. Methods: The Revised Clinical Interview Schedule (CIS-R) measured current neurotic symptoms. Questions on abuse and eating disorders were adapted from the Female European Addiction Severity Index. Findings: In their lifetime, 71% (184/260) had been emotionally abused, 65% (168/260) physically abused and 50% (129/259) sexually abused. In addition, 85% (227/266) met threshold for a neurotic disorder (CIS-R ≥ 12) and 71% (188/266) reported a severity of current neurotic symptoms likely to need treatment (CIS-R ≥ 18). Stepwise multiple logistic regression found that ever suffering from bulimia, anorexia and/or binge eating (OR 4.10, 95% CI 1.76–9.58), adult emotional abuse (OR 2.98, 95% CI 1.57–5.65), being prescribed psychiatric medication in the last 30 days (OR 2.95, 95% CI 1.18–7.38), and 12-month dependence on illicit tranquillizers (OR 2.51, 95% CI 1.29–4.89) were associated with CIS-R ≥ 18. Results were compared for participants attending each of the three services. Conclusions: The findings demonstrate the multiple and complex needs of female drug users that may require medical, mental health and drug use treatment.