The association between opiate addiction and psychopathology has a long history which is now partially supported by empirical data. For example, opiate addicts have been shown to have high rates of depression (Dorus, 1980; Lehman, 1972; Robins, 1974; Rounsaville, 1979; Steer, 1980; Wieland, 1970; Weisman, 1976), antisocial personality characteristics (Craig, 1979), schizophrenia or schizotypal features (Sheppard, 1969; Hekimian, 1968; Zimmering, 1952), manic symptomatology (Craig, 1979; Flemmenbaum, 1974), and alcoholism (Belenko, 1979). The major problem to date, in the studies of psychopathology in opiate addicts, is the measure of psychopathology which has usually been dimensional symptom or personality scales. Diagnostic techniques, particularly the more recently improved measures, have rarely been applied to the opiate addict (Ling, 1973). The result is that there has been a gap between general psychiatric practice and the treatment of opiate abusers. This gap is reflected in the fact that opiate addicts are usually treated in separate specialty clinics. The isolation of the addict in separate treatment programs and from recent developments in psychiatric diagnostic practice could lead to missed opportunities for useful treatment. For example, the opiate addict who is also bipolar might benefit from lithium, or the addict who is also depressed, might benefit from treatment with a tricyclic antidepressant.

 

This paper presents data on the rates of specified psychiatric disorders according to Research Diagnostic Criteria (RDC) (Spitzer, 1978) derived from a survey of opiate addicts. While the population does not derive from a probability sample of a community, it does represent a large and heterogenous group of addicts from a variety of treatment services. With one exception (Ling, 1973), this study represents the first published report of the newer approaches to psychiatric diagnosis applied to a sample of opiate addicts.

 

METHODS

 

Setting and Sample

 

Subjects were evaluated at the Yale University Drug Dependence Unit of the Connecticut Mental Health Center in New Haven, Connecticut. Psychiatric diagnosis was obtained on five hundred thirty-three (533) subjects who were contacted in the following manner: three hundred fifty-four (354) addicts were evaluated as they applied for treatment at the Screening and Evaluation Unit; one hundred twenty (120) subjects were members of the methadone maintenance program; and sixty (60) subjects were Hispanics who were evaluated in Spanish and were evaluated on application to treatment (n=30) or after entering a residential therapeutic community for Hispanic patients (n=30).

 

Subjects in all populations surveyed were paid for participating in the study and were interviewed only after informed written consent was obtained. For this study, opiate addiction was defined according to Research Diagnostic Criteria which require sustained regular use of opiates, signs of withdrawal when drug use is discontinued and indication that use of drugs has led to major changes in the individual's functioning (eg, committing criminal acts).

 

Diagnostic Techniques

 

Information for making diagnostic judgements was collected on the Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott, 1978). On the basis of the information collected on the SADS, the subjects were classified on the Research Diagnostic Criteria (RDC) which are a set of operational diagnostic definitions with specific inclusion and exclusion criteria for a variety of nosologic groups (Spitzer, 1978).

 

Interviewers, Training Reliability

 

There were five raters with Masters and Bachelor-level education and previous experience in clinical psychiatry and interviewing. Under the supervision of a psychiatrist, the raters received three months of training on the SADS and RDC. In order to conduct interviews for this study, it was required' that the rater complete five consecutive, conjoint interviews on which RDC diagnoses were in complete agreement with those of a more experienced rater. After training, reliability was periodically spot-checked on 6 percent of the sample and found to be excellent. Overall, 40 reliability interviews were completed in which one rater interviewed and a second rater observed. On the basis of these ratings, inter-rater agreement was very good with Kappa coefficients (Barthko, 1976) ranging from 0.72 to 1.0 in different diagnostic categories (Rounsaville, 1983).

 

RESULTS

 

Current Rates of Psychiatric Disorders

 

Current rates of disorders that are considered to have both current and past episodes are listed in Table 1. Depression is the most commonly diagnosed symptomatic condition as 23.8 percent of the sample were in a current episode of major depression at this evaluation. Other affective disorders, including minor depression (2.3 percent), manic disorders (0 percent), and hypomanic disorder (0.9 percent) were comparatively infrequently diagnosed, as were schizophrenia (0.2 percent) and schizoaffective disorders (1.5 percent). Only small fractions of the sample were in current episodes of panic (0.9 percent), obsessive compulsive (1.3 percent) or generalized anxiety (0.9 percent) disorders. However, a substantial minority had a current phobia (9.2 percent) or abused alcohol to a degree that met the criteria for a current episode of alcoholism (13.7 percent).

 

Lifetime Rates of Psychiatric Disorders

 

Table 2 shows that 86.9 percent of the addicts surveyed met the criteria for some psychiatric disorder exclusive of drug addiction in their lifetime.

 

Looking at the lifetime rates of specific disorders, the most commonly diagnosed disorders were major depression 53.9 percent, alcoholism 34.5 percent, antisocial personality 26.5 percent, intermittent depression 18.8 percent, labile personality 16.5 percent, phobic disorder 9.6 percent, schizotypal features 8.4 percent, minor depression 8.4 percent, other psychiatric disorders 6.8 percent, hypomanic disorder 6.6 percent, and generalized anxiety disorder 5.4 percent. All other disorders, including schizophrenia, schizoaffective disorders, mania, cyclothymic personality, obsessive compulsive disorder, panic disorder and Briquet's disorder were found in less than 5 percent of the sample. When affective disorders are combined, it is apparent that opiate addicts in this sample are at high risk in that 74.3 percent met the criteria for some affective disorder.

 

Multiple Diagnoses

 

RDC diagnoses are not mutually exclusive and multiple diagnoses were common in our sample. To evaluate, the presence of multiple diagnoses, similar categories were grouped so that six types of disorders were defined: depressive/dysphoric disorders (major depression, minor depression, intermittent depression, labile personality, cyclothymic personality), manic disorders (mania, hypomanic disorder), schizophrenic disorders (schizophrenia, schizoaffective disorder, depressed and manic), anxiety disorders (obsessive compulsive, generalized anxiety, panic, phobic), alcoholism, and personality disorders (antisocial, Briquet's, schizotypal features). Using this system, 13 percent had no disorders, 35 percent had one category of disorder, 31 percent had two, 16 percent had three, and 5 percent had four or five.

 

DISCUSSION

 

The most striking finding of this study was that 70.3 percent of our sample of opiate addicts had a current psychiatric disorder and 86.9 percent met diagnostic criteria for at least one psychiatric disorder other than drug abuse at some time in their lives. Moreover, over half (52 percent) had two or more diagnoses in addition to drug abuse. These rates are far higher than those found in a community sample derived from a survey conducted in the New Haven area where the current rates for any psychiatric disorder were 17.8 percent (Weissman, 1978). The specific disorders in which rates were substantially higher in addicts than in normals include major and minor depression, chronic minor mood disorders (intermittent depression, labile personality, cyclothymic personality), alcoholism, antisocial personality, phobic disorder and generalized anxiety disorder. These higher rates were detected despite the average age of this sample being somewhat lower than that in the New Haven survey, giving the addicts a shorter time at risk for disorders (Weissman, 1978). The great majority of psychiatric disorders in our sample are accounted for by chronic or episodic depressive disorders, antisocial personality and alcoholism.

 

Our finding that over two thirds of our sample have either chronic or episodic depressive disorders extends previous findings using symptom scales and personality measures (Dorus, 1980; Lehman, 1972; Robins, 1974; Rounsaville, 1979; Steer, 1980; Wieland, 1970; Weissman, 1978) which have indicated that depressive symptoms are common in opiate addicts. Our findings are consistent with the clinical theories of Wurmser (1974) and Khantzian (1977) who suggest that a central problem for the typical addict is regulation of affect and vulnerability to dysphoria. Regarding this hypothesis, it is noteworthy that dysphoric disorders were differentially associated with all other diagnostic categories except schizophrenic disorders.

 

The finding that a substantial minority of our sample met criteria for antisocial personality is, if anything, surprisingly low given earlier empirical literature and psychodynamic writings suggesting that the typical addict is sociopathic. Our data suggest, instead, that the typical addict is either chronically depressed or vulnerable to episodic depressions. This seeming contrast may reflect genuine changes in the addict population over time, or differences in the kinds of assessments made. In the current study, relatively stringent criteria were used to define antisocial personality, requiring childhood antisocial behavior in addition to adult antisocial behavior that is judged to be independent of the need to obtain drugs. Hence, many addicts in our sample who have performed repeated antisocial acts did not qualify for a diagnosis of antisocial personality, and this may account for the relatively low rate of this diagnosis in the current study. In addition, the prevalence of antisocial personality among addicts may have been exaggerated in previous studies through use of the MMPI psychopathic deviance scale, an empirically derived instrument from which Astin (1959) has identified five factors: (1) self-esteem, (2) hypersensitivity, (3) social maladjustment, (4) emotional deprivation, and (5) impulse control. Many of the items contained in the self-esteem, hypersensitivity, and emotional deprivation groupings are highly suggestive of depression. Moreover, our data show that antisocial personality and depression are not incompatible, even though the typical view of sociopaths would suggest that they are insulated from dysphoria. As we show elsewhere, in our sample, there was a significant association between dysphoric disorders (primarily depression) and personality disorders (primarily antisocial behavior). Stating a commonly held psychoanalytic view, Bursten (1973) has hypothesized that manipulative character traits serve the purpose of defending against powerful underlying feelings of depression, inferiority and emptiness.

 

The findings that 13.7 percent of the addicts were in current alcoholic episodes and 34.5 percent were alcoholics some time in their lives, extends previous findings (Belenko, 1979) and underscores the need for multimodality treatment aimed at different types of substance abuse. Other disorders which we found in higher rates than might be expected in the general population, including anxiety disorders, hypomania and schizotypal features, were mild and affected a comparatively small minority of our sample. In addition, the validity of these categories may be limited in addicts due to relatively low diagnostic stability (Rounsaville, 1982). Mania and schizophrenic disorders were diagnosed no more frequently than might be expected in a general population. This finding of no excess of schizophrenia or mania in addicts seems to contradict speculations (Flemmenbaum, 1974; Kleber, 1978) suggesting that individuals with these disorders may use opiates to contain psychotic or manic symptomatology. However, since RDC diagnoses are based on overt symptomatology, we cannot rule out the possibility suggested by Kleber and Gold (1978) that early and continued use of narcotics and other CNS depressants may contain symptomatology and result in comparatively attenuated or masked forms of the disorders. If this were the case, our findings that a comparatively high number of addicts in our sample had hypomania (6.6 percent) or schizotypal features (8.4 percent) might be seen as supporting a view of opiates as partial self-treatment for schizophrenia or mania. More intensive study of addicts with these mild diagnoses would be needed to follow up this issue.

 

Treatment Implications

 

Our finding that the great majority of addicts have secondary psychiatric disorders underscores the importance of detecting and treating psychological conditions in opiate addicts. We will focus this discussion on the three major categories of diagnosis: depressive disorders, antisocial personality, and alcoholism.

 

Regarding depression, numerous studies have suggested the value of psychological and pharmacological treatments for episodic disorders and a recent study by Akiskal et al (1980) suggests the value of pharmacotherapy for selected types of chronic, minor mood disorders. In the two well-designed studies-of tricyclic antidepressants as treatment for depression in opiate addicts, results are mixed with one study showing superiority of tricyclic over placebo and the other showing no difference (Woody, 1975; Kleber, 1982). Moreover, a high dropout rate from studies evaluating antidepressant pharmacotherapy in addicts has also been found in several centers (Edward Khantzian, M.D., personal communication) highlighting the problem of using pharmacotherapy for many addicts who are depressed. With this in mind, studies under way are testing out the value of individual psychotherapy for opiate addicts.

 

The finding of a substantial number of addicts with alcoholism suggests the importance of coordinating drug and alcohol programs, which are usually administered separately and of incorporating techniques usually reserved to alcohol treatment in drug treatment programs.

 

Regarding the substantial minority of our addicts with antisocial personality, there is no specific treatment for this type of patient. Moreover, research in personality change in drug treatment has shown that psychopathic traits do not change even when changes are detected in other characteristics such as locus of control and depression (DeLeon, 1973; Sutker, 1974; Rounsaville, 1980). Nevertheless, knowing the diagnosis may help alert the clinician to the need for definition of rules and limit setting for patients with this disorder.

 

Diagnosis is only a first step toward effective treatment. Our findings suggest that most addicts have secondary psychiatric disorders. Further work will be needed to develop effective means of treating various diagnostic subgroups. Although the precise treatment implications of a given psychiatric disorder may be unclear, it is clear that adequate diagnosis is necessary in order to call attention to the full range of the addict's problems. Systematic assessment of psychopathology should be incorporated into drug programs.

 

The system used in the current study, the Schedule for Affective Disorder and Schizophrenia, coupled with the Research Diagnostic Criteria, has much to recommend it as a means of accurately and inexpensively detecting psychiatric disorders. If carefully trained, drug counselors could use the system. As we have shown elsewhere, non-physicians using the SADS were more likely to detect psychiatric disorders than psychiatrists using an open ended interview and the DSM III criteria (Rounsaville, 1980). Moreover, although it does not contain as wide a range of diagnoses as the DSM III, a range of the more important diagnoses is covered.

 

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