Association of depression and anxiety with cardiovascular co-morbidity in a primary care population in Latvia: a cross-sectional study.

BACKGROUND: Cardiovascular (CV) diseases (CVDs) are the leading cause of mortality worldwide. Globally, there is a growing interest in understanding and addressing modifiable psychosocial risk factors, particularly depression and anxiety, to prevent CVDs and to reduce morbidity and mortality. Despite the high premature mortality rate from CVDs in Latvia, this is the first Latvian study to examine the association of depression and anxiety with CVD morbidity in a primary care population. METHODS: This cross-sectional study was carried out in 2015 within the framework of the National Research Program BIOMEDICINE at 24 primary care facilities throughout Latvia. Consecutive adult patients during a one-week time period at each facility were invited to join the study. Assessments onsite included a 9-item Patient Health Questionnaire (PHQ-9) and a 7-item Generalized Anxiety Disorder scale (GAD-7) followed by a socio-demographic questionnaire and measurements of height, weight, waist circumference, blood pressure, and total cholesterol. The diagnostic Mini International Neuropsychiatric Interview (MINI) was conducted over the telephone within 2 weeks after the visit to the general practitioner. A multivariate model was developed using binary logistic regression. RESULTS: From the 1565 subjects (31.2% male), CVD was detected in 17.1%. Depression screening was positive (PHQ-9 ≥ 10) for 14.7%, and anxiety screening was positive (GAD-7 ≥ 10) for 10.1% of the study subjects. According to the MINI, 10.3% had current and 28.1% had lifetime depressive episode, and 16.1% had an anxiety disorder. Depression, not anxiety, was statistically significantly related to CVDs with an odds ratio (OR) of 1.52 (p = 0.04) for current depressive symptoms (PHQ-9 ≥ 10) and 2.08 (p = 0.002) for lifetime depressive episode (MINI). CONCLUSIONS: Current depressive symptoms (PHQ-9 ≥ 10) and a lifetime depressive episode (according to the MINI) were significantly associated with increased risk of CV morbidity. Therefore, CV patients should be screened and treated for depression to potentially improve the prognosis of CVDs. Enhanced training and integration of mental health treatment in Latvian primary care settings may improve clinical outcomes.

Association between sweet preference and paternal history of alcoholism in psychiatric and substance abuse patients.

BACKGROUND: The relationship between preference for stronger sweet solutions and propensity to excessive alcohol drinking is supported by both animal and human studies. This study was designed to test the hypothesis that sweet preference is associated with the genetic risk of alcoholism as measured by a paternal history of alcoholism. METHODS: Participants were 180 patients admitted to a residential treatment program for the treatment of alcoholism, drug dependence, or psychiatric conditions. In addition to a routine medical examination, patients completed the standard sweet preference test twice (on the 9th and 24th days after admission), and the family history of alcoholism was evaluated. RESULTS: Sweet preference was shown to be stable over time. It was strongly associated with a paternal history of alcoholism, with family history-positive patients approximately 5 times more likely to prefer stronger sweet solutions than family history-negative subjects. Such factors as dependence on alcohol, cocaine, opiates, cannabis, other drugs (including prescription drugs), and tobacco smoking, as well as demographics (gender and age), did not significantly interfere with association between sweet preference and paternal history of alcoholism. CONCLUSIONS: These findings provide some support for the hypothesis that preference for stronger sweet solutions is associated with a genetic predisposition to alcoholism as measured by a paternal history of alcoholism.

Nicotine transdermal patch and atypical antipsychotic medications for smoking cessation in schizophrenia.

OBJECTIVE: Schizophrenic patients have high rates of cigarette smoking. The authors compared the outcomes of two group psychotherapy programs for smoking cessation in patients with schizophrenia or schizoaffective disorder who were also treated with the nicotine transdermal patch and with either atypical or typical antipsychotic medications. METHOD: Forty-five subjects were randomly assigned to 1) the group therapy program of the American Lung Association (N=17) or 2) a specialized group therapy program for smokers with schizophrenia (N=28) that emphasized motivational enhancement, relapse prevention, social skills training, and psychoeducation. All subjects participated in 10 weeks of treatment with the nicotine transdermal patch (21 mg/day) and 10 weekly group therapy sessions and continued to receive their prestudy atypical (N=18) or typical (N=27) antipsychotic medications. Outcome variables included treatment retention, rate of smoking abstinence, and expired-breath carbon monoxide level. RESULTS: Smoking abstinence rates did not differ in the two group therapy programs. However, atypical antipsychotic agents, in combination with the nicotine transdermal patch, significantly enhanced the rate of smoking cessation (55.6% in the atypical agent group versus 22.2% in the typical group), which was reflected by a significant effect of atypical versus typical agents on carbon monoxide levels. Risperidone and olanzapine were associated with the highest quit rates. CONCLUSIONS: The results suggest that 1) smoking cessation rates with the nicotine transdermal patch are modest in schizophrenia, 2) specialized group therapy for schizophrenic patients is not significantly different from American Lung Association group therapy in its effect on smoking cessation, and 3) atypical agents may be superior to typical agents in combination with the nicotine transdermal patch for smoking cessation in schizophrenia.

Characteristics of participants and nonparticipants in medication trials for treatment of schizophrenia.

OBJECTIVE: The study compared the characteristics of patients who participated in efficacy trials of medications for treatment of schizophrenia with those of the other patients in the clinical population from which the trial participants had been selected. METHODS: Study participants from ten trials of treatment efficacy conducted at a community mental health center in the early and mid-1990s were compared with nonparticipants using data on demographic and diagnostic characteristics and service utilization from the center's administrative database. Six of the trials selected patients with schizophrenia and no concurrent substance use disorder, and four selected patients with dual diagnoses of schizophrenia and a substance use disorder. RESULTS: Compared with nonparticipants, participants in both types of trial were about six to eight years younger, were two to four times less likely to have ever married, and used more services. Participants in trials that selected patients with no substance use disorder were more likely to be high school graduates and were four times more likely to work full time, compared with nonparticipants. Participants in trials that selected patients with dual diagnoses were likely to be minorities and less likely to have medical comorbidities, compared with nonparticipants. CONCLUSIONS: Participants in treatment efficacy trials differed substantially from nonparticipants. Some characteristics of the trial participants, including reduced likelihood of ever having been married and male gender, have been associated with poorer treatment outcomes in earlier studies. Other characteristics, such as younger age and greater likelihood of having graduated from high school and of working full time, have been associated with better outcomes.

Buprenorphine vs methadone maintenance treatment for concurrent opioid dependence and cocaine abuse.

BACKGROUND: Buprenorphine, a partial mu-agonist and kappa-antagonist, has been proposed as an alternative to methadone for maintenance treatment of opioid dependence, especially for patients with concurrent cocaine dependence or abuse. This study evaluated whether higher maintenance doses of buprenorphine and methadone are superior to lower doses for reducing illicit opioid use and whether buprenorphine is superior to methadone for reducing cocaine use. METHODS: A total of 116 subjects were randomly assigned to 1 of 4 maintenance treatment groups involving higher or lower daily doses of sublingual buprenorphine (12 or 4 mg) or methadone (65 or 20 mg) in a double-blind, 24-week clinical trial. Outcome measures included retention in treatment and illicit opioid and cocaine use as determined by urine toxicology testing and self-report. RESULTS: There were significant effects of maintenance treatment on rates of illicit opioid use, but no significant differences in treatment retention or the rates of cocaine use. The rates of opioid-positive toxicology tests were lowest for treatment with 65 mg of methadone (45%), followed by 12 mg of buprenorphine (58%), 20 mg of methadone (72%), and 4 mg of buprenorphine (77%), with significant contrasts found between 65 mg of methadone and both lower-dose treatments and between 12 mg of buprenorphine and both lower-dose treatments. CONCLUSIONS: The results support the superiority of higher daily buprenorphine and methadone maintenance doses vs lower doses for reducing illicit opioid use, but the results do not support the superiority of buprenorphine compared with methadone for reducing cocaine use.

Dual diagnosis in primary care. Detecting and treating both the addiction and mental illness.

The initial phase of treatment includes engaging the patient in a discussion about the doctor's concerns and providing patients with information about the problems as well as the possibility of change. Treatment of dual disorders often requires a heightened awareness of the consequences of the problem and the development of a realistic plan for change. The treatment plan must attempt to evaluate and treat the addiction and the psychiatric and medical illnesses.

Substance abuse and schizophrenia: editors' introduction.

Most individuals with schizophrenia have problems with abuse of substances ranging from licit substances, such as nicotine, to illicit ones, such as cocaine. This comorbidity may reflect self-medication, as well as a biological susceptibility to both disorders. Twin studies have suggested that this biological susceptibility may involve genetic factors. Other biological risk factors may involve the medications used to treat schizophrenia, which may produce symptoms that provoke abuse of drugs to relieve negative symptoms or may even enhance the euphoric response to abused drugs. The articles in this issue address several research areas related to substance abuse and schizophrenia, including the differential diagnosis of schizophrenia and organic disorders induced by substance abuse and the impact of substance abuse on the course of early schizophrenia. The management of substance-abusing schizophrenia patients requires a careful balance of pharmacotherapy and psychotherapies, and atypical antipsychotic agents may be particularly helpful. Psychotherapy needs to focus both on the management of affect and on the adequate monitoring of drug abstinence.

Motivation to quit using substances among individuals with schizophrenia: implications for a motivation-based treatment model.

Although the motivation to quit using substances is an important prognostic and treatment-matching factor in substance abuse treatment, there is limited information on motivation to quit among individuals with schizophrenia. This study used the five-stages-of-change model to evaluate the motivational levels of 497 individuals with schizophrenia or schizoaffective disorder in an outpatient mental health clinic. Rates of substance abuse, motivation levels to quit each specific substance, and correlates to motivational levels were evaluated. At least one substance use disorder was diagnosed in 224 of the subjects (45%); however, there was significant variability among the caseloads of the outpatient division teams. The patients in the triage/acute services and community outreach teams had substance abuse rates of about 70 percent. Most subjects had low motivation to quit substances, and the rates varied according to substance (range of 41% for opiates to 60% for cocaine). Treatment-matching strategies are suggested in the motivation-based treatment model.

Schizophrenia and nicotine use: report of a pilot smoking cessation program and review of neurobiological and clinical issues.

Nicotine use is a major public health problem that increases medical morbidity and mortality. Nicotine's action and the pathobiology of schizophrenic disorders have common neurobiological substrates. Tobacco smoking alters medication blood levels and effectiveness, modifies psychiatric symptoms, and is a clue for other substance abuse. This article presents an evaluation of a smoking cessation program for 24 smokers with schizophrenia. Fifty percent completed the program, 40 percent decreased use by 50 percent, and 13 percent remained abstinent (carbon monoxide verified) for 6 months. Nicotine replacement, motivational enhancement therapy, and relapse prevention behavioral therapy were important components of treatment. Pharmacotherapy strategies of a higher-dose nicotine patch, combining nicotine gum and a patch, and augmentation medication to nicotine replacement should be evaluated in future studies in this population.

Evidence for reduced dopamine D2 receptor sensitivity in postwithdrawal alcoholics.

Dopamine D2 receptor sensitivity was assessed in the postwithdrawal period in alcoholics. Growth hormone (GH) responses to dopamine D2 agonist bromocriptine were measured in eight DSM-III-R alcohol-dependent subjects who were 2 weeks or more postalcohol withdrawal. Their responses were compared with eight nonalcoholic controls. After an overnight fast, each subject received 1.25 mg of bromocriptine orally, and serial samples of GH were taken over a 3-hr period. There was a significantly blunted delta GH response (mean +/- SE) in the alcoholic group, 2.3 mU/liter (+/- 1.4) relative to controls, 7.7 mU/liter (+/- 1.2) (t = 2.96, df = 14, p = 0.01). There was a significantly blunted peak GH response (mean +/- SE) in the alcoholic group, 5.36 mU/liter (+/- 2.1) relative to controls, 9.04 mU/liter (+/- 5.0). This difference also reached statistical significance (t = 2.32, df = 14, p = 0.035). A repeated-measures ANOVA yielded a significant within-subjects effect of time [F(4,54) = 4.08, p = 0.0057], a significant within-subjects effect of group [F(1,14) = 5.6, p = 0.0329], and an almost significant group x time interaction [F(4,54) = 2.45, p = 0.056]. This result implies a relative dopamine D2 receptor subsensitivity in alcoholics in the postwithdrawal period.

D-fenfluramine-induced prolactin responses in postwithdrawal alcoholics and controls.

Serum prolactin response to the serotonin agonist D-fenfluramine were measured in 19 DSM-111-R male alcoholics, 2.5 or more weeks postalcohol withdrawal. Prolactin responses were compared with nine healthy nonalcoholic male controls. After an overnight fast, each subject received 30 mg of D-fenfluramine orally, and serial samples of serum prolactin were taken over a 4-hr period. D-fenfluramine caused a significantly attenuated peak delta-prolactin response in the alcoholics relative to the controls (p = 0.05). A repeated-measures ANOVA of delta-prolactin yielded a significant within-subjects effect of time (p < 0.05), a within-subjects effect of group that reached significance (p = 0.05), and a nonsignificant group by time interaction. The delta-prolactin value at time points 60 and 240 min postadministration of the probe was significantly attenuated in the alcoholic group, with p < 0.05. There was also some evidence for a diminished serotonergic response in those alcoholics with a negative family history. The delta-prolactin response did not correlate with subjects' age, duration of alcohol use, duration of abstinence from alcohol, severity of alcohol dependence, or age of onset. Results imply a relative subsensitivity of the serotonin system in postwithdrawal alcoholics, and this may be primarily of the 5-HT2 receptor.

Desipramine, amantadine, or fluoxetine in buprenorphine-maintained cocaine users.

The clinical efficacy of promising cocaine anti-craving medications was examined in combination with buprenorphine. Twenty-one opioid-dependent cocaine abusers were enrolled in a double-blind, 12-week trial in which they received on a daily basis buprenorphine (8 mg, s.l.) plus either desipramine (150 mg, p.o.), amantadine (300 mg, p.o.), or fluoxetine (60 mg, p.o.). Urine samples and self-reported drug use were obtained 1-3 times/week. The order of greatest patient retention across the 12 weeks was desipramine (83.3%) > amantadine (66.7%) > fluoxetine (20.0%). The desipramine and amantadine groups appeared to have greater increases in opioid- and cocaine-free urines than the fluoxetine group. These results suggest that desipramine and amantadine may facilitate greater opioid and cocaine abstinence than fluoxetine.

Effects of clozapine on smoking in chronic schizophrenic outpatients.

BACKGROUND: The effects of clozapine administration on smoking were examined in chronic schizophrenic outpatients. METHOD: Twenty-nine of 30 schizophrenic outpatients enrolled in a university-affiliated Community Mental Health Center clozapine clinic were retrospectively surveyed by semistructured questionnaire regarding smoking before and after clozapine administration. RESULTS: Smokers comprised 62% (N = 18) of patients, and within this group, there was a significant decrease in reported daily cigarette use during clozapine treatment compared with level of use when patients had been treated with typical neuroleptics (1.67 +/- 1.13 vs. 1.26 +/- 0.72 packs/day, p = .025). CONCLUSION: Clozapine may alter smoking behaviors in chronic schizophrenics.

Antisocial personality disorder as a prognostic factor for pharmacotherapy of cocaine dependence.

Pharmacotherapy response was compared in 94 cocaine-abusing methadone patients with (n = 75) and without (n = 19) antisocial personality disorder (ASP), in a 12-week, randomized, double-blind trial using desipramine 150 mg daily (n = 30), amantadine 300 mg daily (n = 33), and placebo (n = 31). Retention was lower for the ASP group (ASP 9.6 weeks vs. non-ASP 11.2 weeks). During the first 2 weeks, there was no significant difference in the percentage of cocaine-free urines between the ASP vs. non-ASP patients (9% vs. 18%), but during the last 2 weeks, the non-ASP patients showed a significantly greater percentage of cocaine-free urines (30% vs. 7%). Placebo-treated patients in both groups demonstrated no significant difference in their urine toxicologies comparing the first to the last two weeks of treatment. However, the percentage of cocaine-free urines increased from 15% to 32% in medicated non-ASP patients, but showed no change in medicated ASP patients. Thus, antisocial personality disorder was a poor prognostic factor for treatment retention and continued cocaine abuse, and medication did not improve treatment outcome for the ASP patients, but did for the non-ASP patients.

Psychiatric comorbidity in white and African-American cocaine addicts seeking substance abuse treatment.

OBJECTIVE: Few diagnostic studies have reported rates of psychiatric comorbidity among cocaine addicts according to race. This study examines psychiatric comorbidity in African-American and white cocaine addicts. METHODS: Rates of psychiatric comorbidity were assessed in 263 cocaine addicts seeking substance abuse treatment. The sample included 163 non-Hispanic whites and 100 African Americans. Diagnoses were based on patient interviews using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L). The SADS-L was supplemented to include DSM-III-R criteria for substance abuse or dependence and other psychiatric diagnoses and DSM-III criteria for attention deficit disorder. RESULTS: Overall, 55.7 percent of the cocaine addicts met Research Diagnostic Criteria for a current psychiatric diagnosis, and 73.5 percent met criteria for a lifetime psychiatric diagnosis. Whites and African Americans did not differ significantly in overall psychiatric comorbidity. However, whites had significantly higher rates of life-time major depression, alcohol dependence, attention deficit disorder, and conduct disorder. African-American addicts, particularly women, were more likely to meet criteria for a current diagnosis of phobia. CONCLUSIONS: Psychiatric comorbidity is common among cocaine addicts, and the rates for specific disorders vary by race. Differences in current and lifetime rates should be noted. Cocaine addicts seeking treatment should be assessed for comorbid alcohol dependence and other psychiatric disorders, including anxiety, affective, and personality disorders.