Nady el-Guebaly

Psychiatric comorbidity in pathological gambling: a critical review.

Objective: To critically review the current literature on pathological gambling as regards the significant psychiatric comorbidities associated with it. Method: The authors synthesized information found via electronic searches (MEDLINE) and bibliographic-directed searches in over 60 publications. Results: Pathological gamblers frequently have comorbid substance use disorders. In addition, a subset appear to have comorbid antisocial personality disorder, but they represent a minority when compared with those people who have acquired their antisocial traits as a consequence of their gambling behaviour. A comorbidity with the mood disorders is probable, but methodological concerns and inconsistencies with the data prevent further delineation of this. Emerging research for other disorders possibly associated with pathological gambling is also reviewed. Conclusion: Pathological gambling is associated with significant psychiatric comorbidity. Recommendations for future research are described.

Descriptive Epidemiology of Major Depression in Canada

Objective: The Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2) is the first national study to use a full version of the Composite International Diagnostic Interview. For this reason, and because of its large sample size, the CCHS 1.2 is capable of providing the best currently available description of major depression epidemiology in Canada. Using the CCHS 1.2 data, our study aimed to describe the epidemiology of major depression in Canada. Method: All estimates used appropriate sampling weights and bootstrap variance estimation procedures. The analysis consisted of estimating proportions supplemented by logistic regression modelling. Results: The lifetime prevalence of major depressive episode was 12.2%. Past-year episodes were reported by 4.8% of the sample; 1.8% reported an episode in the past 30 days. As expected, major depression was more common in women than in men, but the difference became smaller with advancing age. The peak annual prevalence occurred in the group aged 15 to 25 years. The prevalence of major depression was not related to level of education but was related to having a chronic medical condition, to unemployment, and to income. Married people had the lowest prevalence, but the effect of marital status changed with age. Logistic regression analysis suggested that the annual prevalence may increase with age in men who never married. Conclusions: The prevalence of major depression in the CCHS 1.2 was slightly lower than that reported in the US and comparable to pan-European estimates. The pattern of association with demographic and clinical variables, however, is broadly similar. An increasing prevalence with age in single (never-married) men was an unexpected finding.

Cue-Induced Brain Activity in Pathological Gamblers

BACKGROUND Previous studies using functional magnetic resonance imaging (fMRI) have identified differential brain activity in healthy subjects performing gambling tasks and in pathological gambling (PG) subjects when exposed to motivational and emotional predecessors for gambling as well as during gambling or response inhibition tasks. The goal of the present study was to determine if PG subjects exhibit differential brain activity when exposed to visual gambling cues. METHODS Ten male DSM-IV-TR PG subjects and 10 matched healthy control subjects underwent fMRI during visual presentations of gambling-related video alternating with video of nature scenes. RESULTS Pathological gambling subjects and control subjects exhibited overlap in areas of brain activity in response to the visual gambling cues; however, compared with control subjects, PG subjects exhibited significantly greater activity in the right dorsolateral prefrontal cortex (DLPFC), including the inferior and medial frontal gyri, the right parahippocampal gyrus, and left occipital cortex, including the fusiform gyrus. Pathological gambling subjects also reported a significant increase in mean craving for gambling after the study. Post hoc analyses revealed a dissociation in visual processing stream (dorsal vs. ventral) activation by subject group and cue type. CONCLUSIONS These findings may represent a component of cue-induced craving for gambling or conditioned behavior that could underlie pathological gambling.

Motivational enhancement and self-help treatments for problem gambling.

Two brief treatments for problem gambling were compared with a waiting-list control in a randomized trial. Eighty-four percent of participants (N = 102) reported a significant reduction in gambling over a 12-month follow-up period. Participants who received a motivational enhancement telephone intervention and a self-help workbook in the mail, but not those who received the workbook only, had better outcomes than participants in a 1-month waiting-list control. Participants who received the motivational interview and workbook showed better outcomes than those receiving the workbook only at 3- and 6-month follow-ups. At the 12-month follow-up, the advantage of the motivational interview and workbook condition was found only for participants with less severe gambling problems. Overall, these results support the effectiveness of a brief telephone and mail-based treatment for problem gambling.

More data on the Addiction Severity Index. Reliability and validity with the mentally ill substance abuser.

The Addiction Severity Index (ASI) is a semistructured interview that collects data from substance abusers in seven problem areas: medical, employment, legal, alcohol, other drug use, family-social functioning, and psychological status. In each area, the clients provide an estimate of the seriousness of the problem and their need for treatment. It has been demonstrated in a number of studies to be reliable, valid, and useful in monitoring treatment changes and in matching substance-abusing clients to treatments. This study investigates the usefulness of the ASI with male and female substance abusers who suffer a concurrent major psychiatric disorder (N = 152). Data on the independence of the problem scales, their internal consistency, interrater reliability, and concurrent validity are presented. It is concluded that: a) the problem areas are independent from each other, underscoring the need for multidimensional assessment; b) interviewer severity ratings provide information in addition to that provided by clients; c) the reliability of the composite scores is generally adequate, with the exception of the legal and family-social scales; and d) further examination of the employment scores is required.

Substance use disorders: sex differences and psychiatric comorbidities.

Objective: This article reviews sex differences in psychiatric comorbidity among individuals with substance use disorders and, in particular, the clinical significance of these differences for treatment outcome among women. Method: We undertook a computerized search of major health care databases. To enhance the search, we drew prior relevant articles from the reference list. Results: Women with alcohol and other drug use disorders present higher rates of psychiatric comorbidity, particularly mood and anxiety disorders, than do men. Moreover, the comorbid diagnosis, particularly of depression, is more often primary in women, while in men the comorbidity is more often secondary to the substance abuse diagnosis. In addition, there is evidence that psychiatric comorbidity is associated with distinct, sex-specific outcomes for substance use treatment. Conclusions: Sex differences in the clinical presentation of substance-dependent individuals with psychiatric comorbidity present specific treatment challenges and opportunities.

Illicit opioid use in Canada: Comparing social, health, and drug use characteristics of untreated users in five cities (OPICAN study)

Most of the estimated 125,000 injection drug users (IDUs) in Canada use illicit opioids and are outside treatment (i.e., methadone maintenance treatment). Empirical data suggest that illicit opioid users outside treatment are characterized by various health and social problem characteristics, including polydrug use, physical and mental morbidity, social marginalization, and crime. Although required for evidence-based programming, systematic information on this specific substance-user population is sparse in Canada to date. This article presents and compares key characteristics of population of illicit opioid users outside treatment in five cities across Canada (OPICAN cohort). Overall, the majority of OPICAN participants regularly used both a variety of illicit opioids and cocaine or crack, reported physical and mental health (e.g., mood disorder) problems, lacked permanent housing, were involved in crime, and had their “ideal” treatment not available to them. However, key local sample differences were shown, including patterns of heroin versus prescription opioid use and levels of additional cocaine versus crack use as well as indicators of social marginalization. Illicit opioid user population across Canada differ on key social, health, and drug use indicators that are crucial for interventions and are often demonstrated between larger and smaller city sites. Differentiated interventions are required.

Retrospective and Prospective Reports of Precipitants to Relapse in Pathological Gambling.

A prospective design was used to explore the precipitants of relapse in a naturalistic sample of pathological gamblers (N = 101) who had recently quit gambling. Relapse rates were high; only 8% were entirely free of gambling during the 12-month follow-up. Relapses were highly variable but occurred most frequently in the evening, when the person was alone and thinking about finances. Moods prior to the gambling were as likely to be positive as negative. The most frequently reported attributions, particularly for major relapses, were cognitions about winning and feeling the need to make money, unlike substance abuse relapses that tend to be attributed to negative affect. Some gender differences were found, but the precipitants of shorter and longer relapses did not differ.

Gender similarities and differences: The prevalence and course of alcohol- and other substance-related disorders

Abstract Changes in womens social role over the past years likely influenced the gender gap in substance use and substance—related disorders, with potentially significant prevention and treatment implications. The authors reviewed the literature about gender differences in prevalence estimates and course of substance—related disorders. Male—to—female ratios of prevalence estimates of substance use are narrowing in different countries. The initiation of substance use is progressively taking place at younger ages, the trend being more dramatic among women as compared to men. Womens accelerated progression to dependence (so—called “telescoping effect”) is a robust finding among alcohol—dependent individuals, although the effect seems to be weaker among younger individuals. As for other drugs, the literature is weaker and further research is needed. It is concluded that womens earlier age of initiation of substance use, faster progression to dependence and under—representation in addiction treatments should be addressed in future health care planning.

Relationship between craving and personality in treatment-seeking women with substance-related disorders.

BackgroundIndividual differences may impact susceptibility to addiction. The impact of personality features on drug craving, however, has not been studied, particularly in women.MethodsNinety-five treatment-seeking women with substance dependence, abstinent for at least 5 and no more than 21 days, were investigated regarding the correlation between personality factors and craving. Personality was assessed using the Temperament and Character Inventory (TCI), the NEO Personality Inventory Revised (NEO-PI-R), and the Barratt Impulsiveness Scale version 11 (BIS-11). Cravings were assessed through the Pennsylvania Craving Scale (PCS), and the Craving Questionnaire (CQ). Anxiety and depressive symptomatology were also recorded.ResultsCraving scores were positively correlated with depression and negatively correlated with number of days abstinent from substance use. Also, craving scores were positively associated with the novelty-seeking factor from the TCI and the total score on the BIS-11, and negatively associated with the conscientiousness and agreeableness facets of the NEO-PI-R.ConclusionFindings suggest that personality features, particularly impulsiveness, can be important predictors of craving in women, which has important implications for treatment planning.