Self-reported premenstrual exacerbation of depressive symptoms in patients seeking treatment for major depression.

BACKGROUND: Very little research has examined the frequency with which women with major depressive disorder experience premenstrual exacerbation (PME) of depression or the characteristics of those who report such worsening. The NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study provides a unique opportunity to evaluate PME in depressed women seeking treatment in primary care or psychiatric settings. METHOD: This report presents data from the first 1500 participants enrolled in the STAR*D study. Premenopausal women with major depressive disorder were asked if they experienced a worsening of their depressive symptoms 5-10 days prior to menses. Those reporting PME were compared with those reporting no PME with regard to sociodemographic characteristics, course of illness features, symptom presentation, general medical co-morbidity, functional impairment, and quality of life. RESULTS: Of 433 premenopausal women not taking oral contraceptives, 64% reported a premenstrual worsening of their depression. Women who reported PME had a longer duration of their current major depressive episode [30.7 (S.D. = 73.7) months versus 13.5 (S.D. = 13.2) months; p=0.001], as well as greater general medical co-morbidity. Women reporting PME were also more likely to endorse symptoms of leaden paralysis, somatic complaints, gastrointestinal complaints, and psychomotor slowing, and were less likely to endorse blunted mood reactivity. CONCLUSIONS: PME is endorsed by the majority of premenopausal women with major depressive disorder and appears to be associated with a longer duration of depressive episode. PME is a common and important clinical issue deserving of further attention in both research and practice.

Smoking during pregnancy and intention to quit: a profile of methadone-maintained women.

The present study characterized cigarette smoking patterns (self-report, carbon monoxide, and cotinine), health-risk perceptions, attitudes, and quitting intentions among pregnant methadone-maintained women (n = 50) enrolled in comprehensive perinatal drug treatment. At baseline, women expressed only moderate motivation and self-efficacy for smoking cessation, and 60% were in the precontemplation stage of change for quitting. Follow-up assessment during pregnancy (n = 40) showed no change in self-reported cigarettes per day or cotinine values. Despite recognition of the personal and fetal health risks of smoking and high social support for quitting, none of the women stopped smoking and few demonstrated reduction. Compared to other pregnant smokers, this sample is characterized by many of the factors associated with difficulty in quitting. Innovative harm-reduction strategies and nicotine replacement medications deserve scientific attention in this high-risk group of tenacious smokers.

MMPI-2 typology of pregnant drug-dependent women in treatment.

The present study examined the validity of Minnesota Multiphasic Personality Inventory-2 (MMPI-2) typology for pregnant drug-dependent women. A 3-cluster solution based on 7 MMPI-2 clinical scales emerged as the best model and was replicated across split-half samples and different primary substance-use diagnoses and treatment modalities. The 3 subtypes identified included Type I (n = 40, 24%) with no clinical elevation, Type II (n = 72, 42%) with elevated psychopathic deviate scale, and Type III (n = 58, 34%) with elevations on all 7 scales. Analyses with interview and self-report measures showed good concurrent validity. Type II had higher retention than Type I and Type III across methadone and medication-free treatments, showing some predictive validity. An a priori method for classifying new cases on the basis of the proposed typology was developed and validated. Study findings support MMPI-2's use with pregnant drug-dependent women for assessment and possibly treatment planning.

Psychopathology in pregnant drug-dependent women with and without comorbid alcohol dependence.

BACKGROUND: Individuals with comorbid alcohol and drug use disorders are at particularly high risk for a variety of problems, including other psychiatric disorders. In general, patients with comorbid alcohol and drug dependence tend to have more severe dependence problems and often have poorer treatment outcomes than individuals with single disorders. For treatment-seeking pregnant women, psychiatric comorbidity can lead to relapse and premature treatment dropout, with adverse consequences to mother and infant. METHODS: Psychopathology, as measured by the Minnesota Multiphasic Personality Inventory-Revised (MMPI-2), was examined in 170 pregnant women admitted to a comprehensive treatment program for cocaine or opiate dependence. Most were single (75%) and African American (80%), with a mean age of 29 years. Thirty-six met DSM-III-R criteria for both alcohol and drug dependence (alcohol positive), whereas 134 were drug dependent only (alcohol negative). RESULTS: Alcohol-positive women had higher levels of psychopathology than alcohol-negative women, with higher scores on scales 2 (Depression), 4 (Psychopathic Deviance), 8 (Schizophrenia), and 0 (Social Introversion; p < 0.05). The mean MMPI-2 profile for alcohol-positive women was 2-4-8 (Depression-Psychopathic Deviance-Schizophrenia; all T-scores > 65), whereas alcohol-negative women had only a scale 4 increase. CONCLUSIONS: Results suggest that pregnant, drug-dependent women with comorbid alcohol dependence present for treatment with greater psychopathology and thus may require more intense interventions than pregnant, drug-dependent women without comorbid alcohol dependence. Alcohol use by pregnant women is particularly important to address in treatment, because alcohol is a known teratogen associated with mental retardation and behavioral problems.

Characterizing pregnant drug-dependent women in treatment and their children.

Alcohol and other drug use during pregnancy represents a major public health concern. This article characterizes a sample of 240 pregnant opioid- or cocaine-dependent women enrolled in the initial residential component of a comprehensive substance abuse treatment program for pregnant women. Data were collected using the Addiction Severity Index, Psychosocial History Form, and Structured Clinical Interview for DSM-III-R. Patients' substance use history, psychiatric comorbidity, social support network, employability, current and previous pregnancies, child custody arrangements, and the father of the current pregnancy, are described to assist providers in tailoring treatment to the specific needs of this population.

Clinical and psychosocial characteristics of substance-dependent pregnant women with and without PTSD.

The present study compared psychiatric and psychosocial functioning in 123 pregnant opiate- and/or cocaine-dependent women with and without a comorbid diagnosis of posttraumatic stress disorder (PTSD). Participants were enrolled in a comprehensive perinatal drug treatment program and completed assessments upon admission. Lifetime diagnostic prevalence of PTSD [Structured Clinical Interview for DSM-IV Disorders (SCID) confirmed] among the sample was 19%. Participants with PTSD (n=24) reported greater need for psychiatric treatment, were more likely to report a previous suicide attempt, and had more previous drug treatments than participants without PTSD (n=99). Women with PTSD were twice as likely to have lifetime Axis I and Axis II disorders and had higher rates of abuse than women without PTSD. Lifetime sexual abuse and ASI family/social composite scores were significant predictors of PTSD. Findings suggest that pregnant drug-dependent women with comorbid PTSD may benefit from specialized treatment services for trauma and/or abuse issues.

Buprenorphine treatment of pregnant opioid--dependent women: maternal and neonatal outcomes.

This open-label prospective study examined maternal and neonatal safety and efficacy outcome measures during and following prenatal buprenorphine exposure. Three opioid-dependent pregnant women received 8 or 12 mg sublingual buprenorphine tablets daily for 15-16 weeks prior to delivery. Results showed that buprenorphine in combination with comprehensive prenatal care was safe and effective in these women. Prenatal exposure to buprenorphine resulted in normal birth outcomes, a mean of 4.33 days (minimum possible=4) hospitalization, and a 'relatively mild' neonatal abstinence syndrome comprised primarily of tremors (disturbed), hyperactive moro and shortened sleep after feeding. The infants required no pharmacological treatment. Onset of neonatal abstinence signs occurred within the first 12 h after birth, peaked by 72 h and returned to below pre-12 h levels by 120 h. It is concluded that buprenorphine has potential utility for the treatment of pregnant opioid-dependent women.

Predictors of outpatient treatment retention: patient versus substance use characteristics.

The present study examined predictors of participation and retention for patients treated at an urban, hospital-based outpatient substance abuse treatment clinic. All patients were interviewed using the Addiction Severity Index (ASI) at the time of admission. Based on lifetime diagnostic history of psychoactive substance abuse/dependence, patients (N=268) were classified as: alcohol-only, drug(s)-only, and alcohol+drug(s). Alcohol-only patients were significantly older, more likely to be Caucasian, married, have less than a high school education, and be employed than drug-only or alcohol/drug patients. Using multiple regression analysis, substance use status did not predict treatment participation and retention, whereas race, gender and employment composite score were significant predictors. Specifically, patients attended more sessions and remained in treatment longer if they were Caucasian, male and had a high employment composite score. These findings suggest that type of substance abuse may be overemphasized as a predictor of outpatient drug-free treatment retention, and that greater emphasis should be placed on tailoring treatment to patients' cultural, gender and vocational needs.

Improving treatment outcomes for pregnant drug-dependent women using low-magnitude voucher incentives.

The aim of this study was to examine the effectiveness of low-magnitude behavioral incentives in improving attendance for abstinence-treated patients and sustaining illicit-drug abstinence for methadone-treated patients. Subjects were randomly assigned to either incentive or control conditions, with target behaviors differing for the two patient groups (attendance for abstinence-treated and abstinence for methadone-treated patients). Controls received no incentives, whereas incentive subjects could earn $5/day in vouchers during the first 7 days of an intensive outpatient treatment. Results showed that $5/day did not significantly improve attendance in abstinence-treated patients or impact drug abstinence in methadone-treated patients. The data suggest that low-magnitude voucher incentives enhanced treatment attendance by methadone-treated subjects. Although modest monetary incentives had some utility in improving attendance in methadone-treated patients, more potent interventions are needed to improve attendance and maintain abstinence in this high-risk population.

Alcohol abuse and dependence in a national sample of psychiatric patients.

OBJECTIVE: To examine clinical characteristics and services being provided to Alcohol Abuse/Dependent (AAD) patients in current psychiatric practice. METHOD: In a national sample of psychiatrists (N = 417), each provided data on three preselected patients (N = 1,245; 51.8% women) that included demographics, DSM-IV diagnoses, treatment setting and health-plan measures. Logistic regression was used to compare patients with and without an AAD diagnosis. RESULTS: Only 12% of patients (n = 151) had an AAD diagnosis. AAD patient care was more frequently subject to utilization review and restriction or specification of medications to be prescribed (formulary). Psychiatrists also perceived greater restrictions on AAD patient care (e.g., requirements to use specific practice guidelines or treatment algorithms). CONCLUSIONS: Findings suggest that health care systems are subjecting treatment patients with AAD to greater scrutiny and may be limiting the extent and nature of care provided to these patients. The low prevalence of AAD among patients being seen by psychiatrists also warrants further attention. Study findings highlight the utility of practice-based research in addiction psychiatry.

Weekly patterns of drug treatment attendance.

OBJECTIVES: This study examined weekly patterns of drug treatment attendance in relation to date of welfare payment receipt and reason for treatment absence. METHODS: Treatment attendance by Medicaid-eligible pregnant women who were drug dependent was examined by calendar week over a 29-month period. RESULTS: Time series analyses showed that attendance was lower during week 1 than week 4. Drug use was the most frequently reported reason for treatment absence during week 1 (25%) but was not reported as a reason during week 3. CONCLUSIONS: Drug-dependent outpatients had increased absences associated with illicit drug use during the first week of the month when welfare payments were received. The generalizability of the findings is unknown.

Personality characteristics of treatment-seeking HIV+ pregnant drug dependent women.

Pregnant, drug dependent women present for treatment with a variety of medical and psychosocial issues. When medical sequelae include HIV infection, effective medical and psychosocial management is essential for both mother and fetus/infant. To better understand and characterize this high-risk population, the present study examined personality features and psychopathology in a sample of HIV+, pregnant, drug dependent women. Personality was assessed using the Minnesota Multiphasic Personality Inventory--Revised (MMPI-2). The mean MMPI-2 codetype, (6-8), although relatively rare in standard drug treatment settings, characterized nearly one-fifth of study participants. The 6-8 codetype is typically associated with unusual thought processes, feelings of hostility and suspiciousness as well as apathy, which may mask symptoms of nervousness, anxiety and depression. Treatment implications of study findings are discussed.

Genetic influences in antisocial personality and drug use disorders.

While an association between antisocial personality disorder (APD) and substance use disorder (SUD) has been frequently observed, the causes of the comorbidity remain unclear. Adoption and twin studies have found evidence of both genetic and environmental influences in APD and SUD. Therefore, comorbidity between APD and SUD may be the result of shared genetic influences, shared environmental influences, or a combination of the two. However, only a limited number of adoption and twin studies have addressed this issue and the results have not been conclusive. In future studies, a distinction should be made between alcohol and drug abuse and between juvenile and adult APD symptoms. Twin samples of adequate size would allow use of structural equation analytical methods for estimation of the relative magnitude of genetic and environmental influences shared between the two conditions, as well as influences contributing to each specifically. Results would be highly relevant for the clinical setting as well as for efforts to identify the genes involved in either trait.

Genetic analysis of diagnostic systems of alcoholism in males.

BACKGROUND: Research into genes involved in alcoholism could benefit from use of diagnostic systems most sensitive to detecting genetic influences. In this study, heritable influences were estimated in a single twin sample with commonly used criteria for alcoholism. METHODS: Male twin probands ascertained through alcohol and drug abuse treatment programs and their same-sex cotwins (54 monozygotic and 65 dizygotic pairs) were diagnosed independently by DSM-III (alcohol dependence and alcohol abuse and/or dependence), Feighner (probable and definite alcoholism), and Cloninger (type 1 and type 2 alcoholism) systems. Using univariate structural equation modeling, heritability was estimated for each diagnostic system. RESULTS: The highest heritability estimates were obtained for Feighner probable alcoholism (h2 = .63), Cloninger type 2 alcoholism (h2 = .54), and DSM-III alcohol dependence (h2 = .52). CONCLUSIONS: Certain diagnostic systems appear to have greater sensitivity for detecting genetic influence and may therefore be more appropriate for use in molecular genetic studies attempting to find genes for alcoholism.

Attendance incentives for outpatient treatment: effects in methadone- and nonmethadone-maintained pregnant drug dependent women.

The effectiveness of behavioral incentives for improving treatment participation and retention in samples of methadone-maintained (n = 66) and nonmethadone-maintained (n = 76) pregnant drug dependent women was examined. Subjects were randomly assigned to receive $0 (standard care) and $1, $5, or $10/day for attending at least 4 h of interdisciplinary treatment programming during the first 7 consecutive days after transfer from residential to outpatient care, with payment dispensed in the form of gift certificates. Methadone-maintained women attended nearly twice as many full treatment days as those not receiving methadone (5.2 vs 2.8 days; P < 0.001) and were retained in treatment significantly longer (86.4 vs 28.9% active in treatment at 30 days). There was no main effect of incentives and no effect on attendance in methadone patients. However, nonmethadone patients offered higher magnitude incentives ($5/$10) attended 3.3 days out of 7 on average, compared to 2.3 days for those offered $0 or $1 per day (t = 1.73; P < 0.05). The study confirmed that methadone maintenance is a powerful therapeutic adjunct which is associated with significantly better treatment retention and participation in ancillary programming than is abstinence-based treatment. It was also found that modest financial incentives can facilitate treatment participation for abstinence-based patients. However, more potent interventions would be needed to match the effectiveness of methadone in this regard.

Twin closeness and co-twin risk for substance use disorders: assessing the impact of the equal environment assumption.

Various environmental variables are hypothesized to operate differentially within identical and fraternal twin pairs. To the extent that these factors are correlated with behavioral outcomes, such as alcohol or drug abuse, traditional twin studies of concordance may be biased. Self-ratings of within-pair emotional closeness, assessed in 169 same-sex twin pairs ascertained through alcohol and drug treatment centers, were used to determine the impact of the twin relationship on concordance for alcohol dependence (N = 130 twin pairs) and other drug abuse and/or dependence (N = 85 twin pairs). In general, identical twin pairs reported significantly closer relationships than fraternal twin pairs, and female twin pairs reported significantly closer relationships than male twin pairs. The data did not indicate an overall effect of closeness on co-twin risk for alcohol dependence. In contrast, closeness was significantly related to co-twin risk for other drug abuse and/or dependence. However, the MZ/DZ concordance difference for other drug abuse and/or dependence remained significant when the effects of within-pair closeness were controlled. Thus, the initial zygosity and sex differences in concordance for substance use disorders cannot be explained solely by differences in twin relationship due to closeness as assessed in this study.

Cost-effectiveness of treatment for drug-abusing pregnant women.

Neonatal intensive care unit (NICU) and drug treatment costs were compared in two groups of pregnant drug abusing women: 100 admissions to a multidisciplinary treatment program and active in care at the time of delivery and 46 controls not entering drug treatment. Clinical measures included urine toxicology at delivery, infant birthweight. Apgar scores and need for and duration of NICU services. Cost measures included drug treatment and NICU costs. Treatment patients showed better clinical outcome at delivery, with less drug use and higher infant estimated gestational age, birthweight and Apgar scores. Infants of treatment patients were also less likely to require NICU services and, for those that did, had a shorter stay. When total cost was examined (including drug treatment), mean net savings for treatment subjects was $4644 per mother/infant pair. The study demonstrates the cost-effectiveness of treatment for pregnant drug abusing women, with savings in NICU costs exceeding costs of drug treatment.

Detecting alcohol problems in drug-dependent women of childbearing age.

Alcohol problems frequently go undetected in drug-dependent individuals. In women of childbearing age, the consequences of unrecognized alcohol problems can be severe. Unfortunately, many drug treatment programs lack resources to conduct formal diagnostic interviews with all program admissions. Using the Structured Clinical Interview for DSM-III-R (SCID) as the "gold standard," the present study compared four clinical tools for assessing alcohol problems in a drug-dependent population. Rates of detecting alcohol problems varied widely (15-76%). The Addiction Severity Index (ASI) and the Family Alcohol and Drug Survey (FADS) yielded the highest sensitivities (96% and 83%, respectively) and specificities (94% and 92%, respectively). Since these instruments require less staff training and background education than the SCID, they offer cost-effective alternatives for efficient screening and assessment of alcohol problems in drug-dependent populations.

The use of support groups among pregnant substance abusers: implications for managed care.

The Better Chance Program offers a model for coordinating managed care for pregnant substance abusers. Support groups may prove useful for other high-risk segments of society inasmuch as they are enrolled in more restrictive health delivery systems.