Sharon Samet

Effects of independent and substance-induced major depressive disorder on remission and relapse of alcohol, cocaine and heroin dependence

AIMS Little is known about the differential effects of independent and substance-induced major depression on the longitudinal course of alcohol, cocaine and heroin disorders when studied prospectively. DESIGN Consecutively admitted in-patients, evaluated at baseline, 6-, 12- and 18-month follow-ups. SETTING Baseline evaluations in a short-stay in-patient urban community psychiatric hospital unit. PARTICIPANTS Adults (n = 250) with current DSM-IV cocaine, heroin and/or alcohol dependence at baseline. MEASUREMENTS The Psychiatric Research Interview for Substance and Mental Disorders (PRISM), used to evaluate independent and substance-induced major depression, alcohol, cocaine and heroin dependence, and other psychiatric disorders. Outcomes for each substance: (i) time (weeks) from hospital discharge to first use; (ii) time from discharge to onset of sustained (≥26 weeks) remission from dependence; (iii) time from onset of sustained remission to relapse. FINDINGS Substance-induced major depression significantly predicted post-discharge use of alcohol, cocaine and heroin (hazard ratios 4.7, 5.3 and 6.5, respectively). Among patients achieving stable remissions from dependence, independent major depression predicted relapse to alcohol and cocaine dependence (hazard ratios 2.3 and 2.7, respectively). CONCLUSIONS Substance-induced and independent major depressions were both related to post-discharge use of alcohol, cocaine and heroin. The findings suggest the importance of clinical attention to both types of depression in substance abusing patients.

Diagnosing comorbidity: concepts, criteria, and methods

Background: The clinical and etiologic implications of comorbid psychiatric and substance-use disorders are relevant across countries and cultures. The DSM-IV now places greater emphasis on the clinical and research utility of the substance-induced disorders classification, and clarifies several important diagnostic issues specific to primary and substance-induced disorders. However, no research consensus exists over the core problem of identifying and differentiating the drug and alcohol intoxication and withdrawal symptoms that can mimic psychiatric symptoms in heavy drinkers and drug users. Objective: To investigate how various diagnostic instruments have measured comorbid psychiatric and substance-use disorders and how each instrument operationalizes the DSM-IV classification. Method: We review the evolution of the concept of comorbidity beginning with its formalization as the ‘primary–secondary’ distinction in the Feighner Criteria. We address the ‘organic–non-organic’ distinction found in the RDC, DSM-III, and DSM-III-R; and finally, review the ‘primary’ and ‘substance-induced’ categories of DSM-IV, DSM-IV-TR and ICD-10. We describe how these distinctions have been operationalized in widely used diagnostic instruments. Conclusion: Further understanding of these classifications and the relationship of co-occurring psychiatric and substance disorders can be accomplished with the range of available measures, particularly the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), which reliably utilizes and refines DSM-IV classification distinctions.

When acute-stage psychosis and substance use co-occur: differentiating substance-induced and primary psychotic disorders.

&NA; Substances such as alcohol, cocaine, amphetamine, and cannabis can produce psychotic reactions in individuals who are otherwise free of serious mental illness. However, persons with primary psychotic disorders, such as schizophrenia and bipolar disorder, who use these substances often present for treatment with signs and symptoms similar to those whose psychosis resulted from the use of drugs alone. While it is often difficult to distinguish substance‐induced from primary psychoses, especially early in the course of treatment, this differential diagnosis has important implications for treatment planning. To help clinicians distinguish these two types of presentations, the authors first review the types of psychotic symptoms that can co‐occur with substance use. They discuss the prevalence and patterns of substance use that have been found in patients with schizophrenia and other primary psychotic disorders and review the negative outcomes associated with substance use in this population. The prevalence of and types of symptoms and problems associated with psychotic symptoms that occur as a result of substance use alone are also reviewed. The authors describe assessment procedures for differentiating substance‐induced and primary psychotic disorders. They stress the importance of accurately establishing the temporal relationship between the substance use and the onset and continuation of psychotic symptoms in making a differential diagnosis, as well as the importance of being familiar with the types of psychological symptoms that can occur with specific substances. The authors review the utility and limitations of a number of diagnostic instruments for assessing patients with co‐occurring psychosis and substance use problems, including The Addiction Severity Index, The Michigan Alcohol Screening Test, and diagnostic interviews such as the Schedule for Affective Disorders and Schizophrenia and the Structured Clinical Interview for DSM. They then discuss the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), an instrument that has been developed to address the lack of a diagnostic interview that is suitable for assessing the comorbidity of substance use and psychiatric disorders. The article concludes with a discussion of the importance of an appropriate match between diagnosis and treatment and the current state of our knowledge concerning the most appropriate types of treatment interventions for patients with substance‐induced psychosis and those with dual diagnoses. (Journal of Psychiatric Practice 2000;6:256–266)

A prospective 2-year study of emergency department patients with early-phase primary psychosis or substance-induced psychosis.

OBJECTIVE The authors examined treatment utilization and outcomes over 2 years among patients admitted to emergency departments with early-phase primary or substance-induced psychosis. The main hypothesis was that patients with substance-induced psychosis would have a more benign course of illness than those with primary psychosis METHOD Using a prospective naturalistic cohort study design, the authors compared 217 patients with early-phase primary psychosis plus substance use and 134 patients with early-phase substance-induced psychosis who presented to psychiatric emergency departments at hospitals in Upper Manhattan. Assessments at baseline and at 6, 12, 18, and 24 months included psychiatric diagnoses, service use, and institutional outcomes using the Psychiatric Research Interview for Substance and Mental Disorders; psychiatric symptoms using the Positive and Negative Syndrome Scale; social, vocational, and family functioning using the World Health Organization Psychiatric Disability Assessment Schedule; and life satisfaction using the Quality of Life Interview. Longitudinal analyses were conducted using generalized estimating equations. RESULTS Participants with primary psychosis were more likely to receive antipsychotic and mood-stabilizing medications, undergo hospitalizations, and have outpatient psychiatric visits; those with substance-induced psychosis were more likely to receive addiction treatments. Only a minority of each group received minimally adequate treatments. Both groups improved significantly over time on substance dependence, psychotic symptoms, homelessness, and psychosocial outcomes, and few group-by-time interactions emerged. CONCLUSIONS Patients presenting to Upper Manhattan emergency departments with either early-phase primary psychosis or substance-induced psychosis improved steadily over 2 years despite minimal use of mental health and substance abuse services.

Feasibility of the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) in an acute psychiatric ward

Background : The highly prevalent comorbidity of substance use disorders and psychiatric disorders represents challenges concerning diagnosis and treatment in acute psychiatric wards. Aims : To study the feasibility of the first Norwegian version of the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) in an acute psychiatric ward. Methods : 61 consecutively admitted substance abusing patients, presenting with mood symptoms, psychotic symptoms, or both, were interviewed. Assessments included variables concerning the way the interviews were carried out. Results : 51% of eligible patients were interviewed. The main reason for non-inclusion was short stay on the ward. Median interview time was 155 minutes and median number of interview sessions was three. Conclusion : It was possible to use the PRISM in a busy acute psychiatric ward. Patients mainly had positive reactions to this extensive interview.