The findings of Drs. Rounsaville, Kleber, and Weissman about psychiatric illnesses in opiate dependent patients are supported by work done in other programs. We have participated in a study funded by the National Institute of Drug Abuse that has done similar diagnostic evaluations on methadone maintained patients, as have Drs. Treece and Khantzian in Boston. Using the SADS-L (the same instrument used by Rounsaville et al), each group found similar results: approximately 25 percent of patients on methadone maintenance have a diagnosis of antisocial personality as defined by the RDC criteria; about 30 percent are suffering a diagnosable depressive illness (either major, minor or intermittent depressive disorder) and about 50 percent have a history of having suffered a depressive disorder at some time in their life. Between 10 and 15 percent have a current anxiety disorder (most commonly generalized anxiety disorder, phobic disorder or obsessive compulsive disorder) and about 15 percent have a current diagnosis of alcoholism. A variety of other diagnoses were found, but these were the most common (1981). The similarity between the findings of Drs. Rounsaville et al and those of the Boston group indicates that these disorders are common and occur with predictable frequency at least among narcotic addicts who are treated in publicly funded programs in these three cities. In addition to these specific problems, a very high proportion of patients had either a current or past history of any kind of psychiatric illness. As mentioned by Dr. Rounsaville, about 85 percent of their patients have a current of past diagnosable psychiatric illness other than substance abuse. These findings support the impression of many clinicians that addicts are a very diverse group when viewed from a psychiatric perspective, and that psychiatric illnesses are seen commonly in substance abuse patients.

 

These findings also present an opportunity to examine the interface between psychiatric illness and addiction. We have had a special interest in this relationship and have studied it in several ways during the last five years. Some aspects of this relationship which we have observed and which seem important are the following:

First, some of these illnesses can be produced (or perhaps attenuated) by different classes of drugs. McLellan et al recently completed a study of a group of substance abuse patients who had been treated at the inpatient unit of the Coatesville VA Medical Center at least once per year between 1972 and 1978 (1979). Judged by their histories of repeated treatment attempts, these patients had been either treatment failures or were unusually resistant to substance abuse treatment. Every patient had been evaluated psychiatrically by a clinician and was given an MMPI at each admission. These patients were subdivided into three groups, based upon their primary drug of abuse. One group used primarily narcotics, another group used primarily stimulants (amphetamines, cocaine), and a third used mainly sedative type drugs (diazepam, barbiturates, synthetic sedative hypnotics). Each of these groups had similar psychiatric pictures when first seen in 1972-both the MMPI scores and clinical evaluations showed no significant differences at their first admission. But when followed over a six-year period, the stimulant abusers developed a very high proportion of schizophrenic-like symptoms and at the last follow-up point, about 25 percent of these patients had been in long-term psychiatric treatment. The sedative abusers developed a very high proportion of depression. Approximately 30 percent of these had made a suicide attempt and over half were moderately to severely depressed upon examination at their six-year follow-up point. Both the MMPI testing and the psychiatric evaluations were done 10 to 14 days after admission to the unit, so the evaluations did not represent acute drug effects. Interestingly the narcotic dependent patients did not seem to change. When first seen in 1972, they had moderately elevated levels of depression and sociopathic behavior, problems which have traditionally been found in this population. When followed up in subsequent years and in 1978 at the six-year point, this group was approximately the same as upon their first admission.

 

The most likely explanation for these findings seems to be that the persistent and repeated use of stimulant drugs produced schizophrenic-like disorders in a significant proportion of the patients who were abusing them. Schizophrenic-like illnesses are a well-known acute effect of stimulant use, thus it makes sense that chronic use can produce a persistent schizophrenic-like illness in patients who repeatedly use them. Similarly, persistent use of depressant drugs seemed to produce depression. Again, this is not inconsistent with the pharmacological effects of depressant drugs. Interestingly, there was a lowering of the IQ in the sedative abusers at the 1978 follow-up when compared to the 1972 evaluation. This would indicate that some brain damage had occurred as a result of the sedative drug abuse. Again, this is consistent with reports in the literature showing evidence of neurological impairment in patients who persistently abuse sedatives.

 

Some of the most striking results of this study were the lack of development of psychiatric disorders in the opiate group. This would indicate that the opiates are relatively non-toxic in terms of their ability to produce major psychiatric disorders. In fact, the possibility exists that opiates may have a modulating or stabilizing effect, and thus may help suppress the emergence of psychiatric disorders (Comfort, 1977). Again, this psychotropic effect of opiates is consistent with the observed pharmacological effects of these drugs, and it has been mentioned as one reason that leads some patients to use narcotics. Table 1 summarizes the findings of this study.

 

The second point is that a general measure of psychiatric severity taken upon admission to treatment appears to correlate with several measures of outcome. Those patients who had the most severe psychiatric problems upon entering treatment appear to do the worst, and those with the least severe problems do the best (McLellan, 1981).

The third important point is that the amount of current drug use probably correlates with the severity of psychiatric symptoms. The data upon which this statement is based comes from a study that we have been doing in which we are looking at the results obtained by using psychotherapy done by trained professionals when combined with counselling services in a methadone treatment program. This study is one in which patients are randomly assigned to receive either counselling plus cognitive-behavioral (CB), or supportive-expressive (SE), psychotherapy, or counselling alone (DC). All patients entering the study are given a thorough evaluation including the SADS-L with RDC and DSM-III diagnoses; social, legal, medical, family and vocational evaluations; and measures of current psychiatric symptoms such as the SCL-90, the Beck, and the SADS-C. Our preliminary results indicate that the patients who were randomly assigned to receive psychotherapy in addition to counselling are doing better as measured by urine test results, methadone dosage, prescribed medications, and other measures of outcome. These results are summarized in Tables 2 and 3 and Figures 1, 2, and 3.

 

When we separate patients who received counselling or counselling plus psychotherapy into those who have high and low levels of psychiatric severity, we find the following results, summarized in Tables 4 and 5 and Figures 4, 5, and 6.

 

As seen in the tables and figures, patients who were judged by the criteria listed in Table 4 to have high or low levels of psychiatric symptoms used correspondingly higher or lower amounts of medication as judged doses of methadone, urine test results and prescriptions for ancillary medicines. Thus, we see a relationship between psychiatric severity and both prescribed and unprescribed drug use. Interestingly, we find that both the psychotherapy and the counselling groups who had low levels of psychiatric severity benefitted about equally from the treatment programs. However, patients with high levels of psychiatric severity appeared to receive minimal benefit from counselling alone whereas they seemed to receive significant benefits from the combination of counselling and psychotherapy. This finding can be of practical interest. Patients with high levels of psychiatric severity may benefit by the use of more highly trained personnel when treated in a methadone program, and they may not improve much unless they receive this extra help. Those with relatively low levels of psychiatric symptoms seem to do well with the routine clinical services and it is probably not necessary to add special treatments for these patients.

Implications: These findings have several implications. One is that illicit drugs use may represent attempts to self-medicate psychiatric symptoms for some patients. For these particular patients, psychiatric problems can contribute to the severity and perhaps to the continuation of the addiction. Insofar as addicts are psychiatrically impaired, which many seem to be, psychiatric illnesses may be important contributors to addiction. The frequency of drug use itself does not seem to be an important determinant of outcome. A second

implication is that the choice of drug may play a significant role in determining whether the person remains stable (or perhaps becomes more integrated), or becomes more disorganized. Here I am referring to the study by McLellan et al in which patients who used sedatives and stimulants developed psychiatric illnesses whereas those who used opiates did not. The last implication is that diagnosis and effective treatment of psychiatric problems, along with other services (such as legal counselling, vocational interventions and appropriate pharmacological support) may improve outcome, especially in patients with high degrees of psychiatric severity.

 

REFERENCES

 

Comfort A: Morphine as an antipsychotic: Relevance of a 19th-century therapeutic fashion. Lancet 2:448-449, 1977

McLellan AT, Luborsky L, Woody GE, O'Brien CP and Kron R: Are the "addiction-related" problems of substance abusers really related? The Journal of Nervous and Mental Disease 169:232-239, 1981

McLellan AT, Woody GE and O'Brien CP: Development of psychiatric illness in drug abusers. N Eng J Med 301:1310-1314, 1979

Nace EP, O'Brien CP, Mintz J, Ream N and Meyers AL: Adjustment among Vietnam veterans drug users: Two years post service. In: Figley CP, PhD (ed) Stress Disorders Among Vietnam Veterans. Brunner/Mazel: New York, 1978 pp 71-128

Reported at project review meeting held by NIDA. Parklawn Building, Rockville, Md. January 24, 1981