Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study.

BACKGROUND: Heroin-assisted substitution treatment for severely opioid-dependent drug users has been available in Switzerland since 1994. Our aim was to ascertain the feasibility, safety, and efficacy of this treatment. METHODS: We did a cohort study in 21 community outpatient treatment centres. We assessed 1969 opioid-dependent drug users, who began heroin-assisted substitution treatment between January, 1994, and December, 2000, to ascertain admission and discharge patterns, and patient characteristics. We also followed up a subset of 237 patients who began treatment between Jan 1, 1994, and March 31, 1995, and who stayed with the programme for at least 18 months. We used questionnaires, interviews, and medical examinations done at entry and after 6, 12, and 18 months to assess somatic and mental health, social integration, and treatment outcomes. FINDINGS: More than 70% (1378) of patients remained in treatment for more than a year. Treatment showed positive effects with respect to health and social outcomes. A long stay in treatment was related to a higher chance of starting abstinence-oriented therapy than a short stay. INTERPRETATION: Heroin-assisted substitution treatment might be an effective option for chronically addicted patients for whom other treatments have failed.

[Heroin-assisted treatment of opiate addicts--former and current research emphasis]. / Die heroingestützte Behandlung von Opiatabhängigen--bisherige und aktuelle Forschungsschwerpunkte.

Heroin-assisted treatment has been examined broadly in Switzerland since 1994 within the context of scientific studies. The goal was to clarify the suitability of this treatment for opiate addicts whom previous therapy had failed to reach. Results of the initial research phase show that the target group could be reached for treatment extending 18 months with a satisfactory retention rate of 69%. The patients could improve their health and social situation during treatment and reduce illegal consumption of narcotics. Studies during the initial years primarily examined the viability of heroin-assisted treatment and its effects on the patients' psychosocial and somatic development. A second study phase ongoing since 1998 pursues the specific importance of medical and psychosocial treatment for patients' health and social development in heroin-assisted treatment. The focal point is the effort to optimise treatment of patients with comorbidity of psychiatric disorders and severe somatic diseases, particularly AIDS. Investigations carried out in Switzerland have been discussed broadly at an international level. Studies on heroin-assisted treatment are also being conducted at present in various countries. In future, co-operation should be further intensified with researchers on an international scale.

[Economic evaluation in a trial of medically controlled prescription of narcotics to dependent users (PROVE)]. / Gesundheitsökonomische Bewertung der Versuche für eine ärztliche Verschreibung von Betäubungsmitteln (PROVE).

In the 1994-1996 trial of medically controlled prescription of narcotics to dependent users, 800 places were ascribed to heroin substitutes and another 200 for methadone and morphine substitutes. The trial was evaluated with the aid of an accompanying research. Among the results demonstrated in the evaluation was an improvement of the health of the participants. The economic assessment was drawn from observations of health effects within a sub-sample of 142 participants from four centers. In a retrospective statistical survey, for each acute illness which could be influenced through the trial, the number of diagnoses was recorded in the first and thirteenth month after study entry. Also, based on a number of representative cases for each of these acute illnesses, the resource use, i.e. the types and numbers of medical products and services rendered to the patients, was recorded. The results showed a clear decline in depressive episodes, skin diseases, digestive system disorders as well as epileptic attacks and intoxication. Treatment costs could be reduced from a total of CHF 94875.--to CHF 21,998.--/month or from CHF 22.27 to CHF 5.15/patient per day. The improvement of somatic and psychic health due to the medically controlled prescription of narcotics resulted in a benefit of CHF 17.11/person per day.

Prescribing narcotics to drug-dependent people in prison: some preliminary results.

AIDS: Switzerland began testing a program in which narcotics are prescribed under medical care for drug-dependent inmates. The goal of the program being run at the Oberschongrun penitentiary is to make drug-dependent people feel better, have the chance of becoming stable in prison, and escape the vicious cycle of committing further drug-related crimes when they are released. Participation in the trial is voluntary. Participants must be at least 20 years of age, been drug dependent for two years, and have undergone unsuccessful drug treatment. An additional selection criterion is illegal consumption of heroin while incarcerated. Issues involved with the trial are described, including the conflicts inherent in prescribing drugs that are usually considered illegal. Preliminary conclusions show that the program is feasible, although there are significant problems in instituting this type of program in an environment that is totalitarian and rigid. The program raises prison role issues of rehabilitation versus punishment.^ieng

Swiss heroin-addicted females. Career and social adjustment.

Studies on gender-related differences among heroin-addicted individuals are uncommon because women usually make up only one quarter of any one sample group. In our sample group of 248 Swiss-German heroin-addicted individuals from different therapeutic programs and prisons, 70 were women (28.2%). Follow-up investigations were conducted after a lapse of 2 years, and after a lapse of 7 years, respectively. Men and women appear to differ with respect to why they begin to use drugs, as well as why they relapse back into drug use. Prior to the commencement of drug abuse, social background concerns and social adjustment dynamics appear to constitute a heavier burden for women than for men. Observations of social functioning and adjustment phenomena made during their drug careers and in the follow-up investigations, however, failed to yield significant statistical differences. The predominant effects of drug use appear to eclipse the gender-related role-pattern. On the basis of our background data, as well as our therapeutic experience, we postulate that for an individual whose sex-role identity is threatened, drug abuse has a stabilizing function, and it carries a message.

The Zurich Study. VII. Insomnia: symptoms, classification and prevalence.

This study describes sleep behaviour and insomnia in a representative cohort of a Swiss population. Interviews were carried out prospectively from age 20-21 to 27-28 years, starting with 292 males and 299 females. Females usually go to bed earlier and sleep 30 min longer than males. Taking into account length and periodicity of insomnia we can distinguish occasional insomnia (OI), repeated brief insomnia (RBI), and continued insomnia (CI), defined by operational criteria. The prevalence of sleep problems is stable from age 21-28, at 36%-40%. CI (prevalence 8%-10%) and RBI (13%-19%) are both medical problems in terms of treatment by professionals (10%-17%) or self-medication (7%-12%). The majority of insomniacs cope with sleep problems in various other ways. Frequency and patterns of symptoms of insomnia are described.

The Zurich Study. V. Anxiety and phobia in young adults.

From data collected within the frame of a longitudinal epidemiologic study of a representative sample population of young adults (the Zurich Study), anxiety disorders--anxiety and phobic states--were analyzed. The current prevalence rate was found to be 2.9% for anxiety states and 4.3% for phobic states, totaling 7.2%. Because of their anxiety disorders, one-fifth of the cases had undergone treatment during the preceding 12 months. Substantial difficulties arose, from the point of view of classification. The currently used categories, such as anxiety states, panic attacks, agoraphobia, simple phobia, social phobia, have more in common than differing symptoms. On a syndromal level, numerous overlapping configurations resulted which can only be artificially forced into the aforementioned diagnostic classes of anxiety disorders. On the symptom level, merely a few operationalized items defined these categories. In this way, most of a broad identical 'nonspecific' symptomatology was not taken into account. This was exemplified by a comparison of anxiety states and agoraphobia. In fact, these two groups did not differ significantly in many symptoms or in SCL-90 profiles, but did show a highly significant difference from control samples. Both groups suffered to the same great degree from depressive, cardiovascular, and gastrointestinal symptoms. We doubt whether any forced categorical diagnostic differentiation of anxiety and phobic states is at all reasonable.

The Zurich Study--a prospective epidemiological study of depressive, neurotic and psychosomatic syndromes. IV. Recurrent and nonrecurrent brief depression.

How common and how significant are brief depressive episodes (BDE) lasting less than 2 weeks? The authors propose splitting the BDE into two groups: one occurring monthly over 1 year of observation, termed 'recurrent brief depression' (RBD), and those occurring less frequently, labeled 'nonrecurrent brief depression' (NRBD). From a medical point of view, the RBD are a relevant group. Different thresholds of definition are tested, the narrowest of which (including occupational impairment and predetermined minimum number of symptoms) is accepted for 'case'-definition. The such defined RBD (SYM) group differs from major depression only by length and frequency of episodes. In a young cohort, its 1-year prevalence rate was found to be 4.4% (males 3.9%, females 4.9%). One-third of these cases needed treatment, a fourth suffered from pronounced subjective and social impairment as well as from persistent suicidal ideation. The self-reporting of subjective impairment, assessed with the SCL-90 symptom inventory and an analog-rating, yields high scores which are in no way inferior to major depression diagnosed with RDC, DSM-III or EDE (SYM) criteria. The RBD (SYM) demonstrate less hypomania than the major depressive disorders. On the other hand, a family history of depression is equally frequent across all groups. The validity of the RBD (SYM) group has yet to be confirmed by a follow-up study, and further research is needed to delineate it from secondary depression. The findings largely support the hypothesis of a continuum from mild and short to more severe, longer lasting depressive syndromes, but they do not exclude heterogeneity of RBD (Angst and Dobler-Mikola 1984b).(ABSTRACT TRUNCATED AT 250 WORDS)

The Zurich Study. VI. A continuum from depression to anxiety disorders?

A representative sample of 456 persons from the normal population aged 22 and 23 years was used to study the overlap of depression with anxiety disorders. The 1-year prevalence rate for major depression (DSM-III), minor depression, and anxiety disorder together was 16.4%. The observed cases of major depression occurred in 36% with anxiety disorder, the cases with minor depression in 60%. On the level of symptoms assessed by a semistructured clinical interview and on the level of self-assessed items of the symptom check list SCL-90, the overlap was even greater. The main finding was that subjects with both diagnoses, depression and anxiety disorder, were more severely affected in general. Discriminant analyses of the SCL-90 scales together with the qualitative distribution of SCL items characterizing depression, anxiety, or phobia, did not disprove the hypothesis of a continuum.

Do the diagnostic criteria determine the sex ratio in depression?

The 1-year prevalence rates and sex ratio of dysphoric mood, brief (BDE, less than 2 weeks) and extensive (EDE, greater than or equal to 2 weeks) depressive episodes and major depression (RDC, DSM-III) from an epidemiologic study are presented. Factors influencing the sex ratio are analyzed: subjective suffering from EDE, social and work impairment were found to an equal degree in both genders. Factors favoring female preponderance: women report more symptoms, men most probably forget symptoms, frequency and length of less recent depressions more readily, women see a physician or proceed to self-medication much more often. Consequently, the identical minimum symptom number for both genders is questioned and occupational impairment suggested as an alternative case-defining criterion.

The Zurich study--a prospective epidemiological study of depressive, neurotic and psychosomatic syndromes. I. Problem, methodology.

The purpose and methodology of a 4-year longitudinal study based on a cohort aged 20 years are presented. A two-stage procedure was chosen; in 1978, 2201 males and 2346 females, aged 19-20, were examined. This sample was representative of the respective age group in the Canton of Zurich. From high and low-scorers (SCL-90), 292 males and 299 females were randomly selected for interview and for a prospective study. Subsequent investigations were carried out by questionnaires and by a personal interview. The instruments chiefly consisted of a semi-structured interview (SPIKE), a clinical syndrome list (SL), a 90-item symptom check list (SCL-90R), a life-event-inventory, scales measuring coping behavior and dissimulation, and an extensive sociological interview dealing with sociodemographic characteristics and social adjustment. This paper gives an account of the methodological aspects of the study.

The Zurich study. II. The continuum from normal to pathological depressive mood swings.

The longitudinal study of a cohort of 591 men and women aged 20 and 21 years respectively at outset, and 23/24 years at a subsequent investigation, was analyzed for the manifestation of depressive syndromes. The syndromes were grouped according to their duration: 1 week once or twice per year (group B), 1 week three or more times per year (C), 2 weeks (D), 4 weeks (E) and 3 months (F). Prevalence rates are given over 1 month, 3 months and 1 year, subdivided by sex. Unexpected identical prevalence rates are found for both sexes up to 3 months. Over 1 year, the ratio shifts to favor the women. Setting out from the hypothesis of a continuum of depressive mood from normal to pathological, groups B to E were examined with respect to the prevailing symptomatology (assessed with an interview and a self-rating questionnaire, the SCL-90R). We found no relevant qualitative differences, only a trend of somatic symptoms becoming more prominent along with increasing duration of episode. Symptomatology thus does not point to further classification. Other criteria, such as subjective impairment, social impairment, illness behavior, discussing depressive mood with parents/friends/employer, treatment, all favor the assumption of a continuum of depressive syndromes from normal to pathological.

The Zurich study. III. Diagnosis of depression.

A 23- to 24-year-old age group representative of the general population of the Canton of Zurich, was used to detect depression. The classifications obtained by means of the Feighner, RDC and DSM-III criteria are compared with our own concept, which differs in some aspects. A minimum of 2 weeks of depression is labeled as EDE (extensive depressive episode). Instead of the presence of a minimum number of depressive symptoms, social impairment at work is first examined as a case-defining criterion (EDE[WORK]); in a second step, a diagnostic threshold of three, and five, depressive symptoms for males and females respectively is adopted (EDE[SYM]). The consequences are presented relating to prevalence, incidence, sex distribution, overlap with other diagnostic concepts, severity, bipolarity and family history. An unequal sex distribution in depression is shown to be an artifact of definition. Preference should go to a case-definition that could be specifically adapted to a given problem. On the whole, the DSM-III and EDE(WORK) criteria appear to be too broad. We will henceforth prefer the RDC and EDE(SYM) criteria, which both, however, necessitate further methodological and empirical study.

The definition of depression.

Prevalence figures of depression usually show a sex ratio for males:females of 1:2. This unequal ratio has been examined by varying the time periods for the calculation of prevalance rates and the criteria for case definition. Based on results of a 20-23 yr-old cohort of 591 males and females studied in Switzerland, some evidence was found to support the hypothesis that an unequal sex ratio is partially due to unequal reporting of depressive symptoms and to differential forgetting, perhaps linked with the male role in society. It is not yet possible to extend the results of this study to older cohorts. Further research would be desirable.

A prospective epidemiological study of psychosomatic and psychiatric syndromes in young adults.

A prospective epidemiological field study of psychosomatic syndromes among 600 young adults in Zurich, Switzerland, is presented. During a period of 3 years, the respondents completed two questionnaires and were once personally interviewed about their psychosomatic and psychological syndromes in the 12 months prior to the inquiring dates. This communication concentrates on the results of the first questionnaire and the personal interview. The anamnestic data as well as the information about the frequency and duration of a number of psychosomatic syndromes serve to formulate a prognosis about the future course of these syndromes. This prognosis will then be compared with the results of the second follow-up consisting of the second questionnaire.

[Sociocultural aspects of depression. Results of an epidemiologic study of young adults in Zurich]. / Soziokulturelle Aspekte der Depression. Ergebnisse einer epidemiologischen Studie an jungen Erwachsenen im Kanton Zürich.

In a general population sample of young adults the sociocultural aspects of the depressive syndrome are investigated. In the context of a theory of social integration the association of depression with the material resources, with social belonging and with self realisation are analysed. There are marked correlations with the perceived fulfillment of basic social needs. The correlations with the structural prerequisites for social integration, however, are much weaker.