Childhood adversity and subsequent mental health status in adulthood: screening for associations using two linked surveys.

AIMS: Accumulating evidence links childhood adversity to negative health outcomes in adulthood. However, most of the available evidence is retrospective and subject to recall bias. Published reports have sometimes focused on specific childhood exposures (e.g. abuse) and/or specific outcomes (e.g. major depression). Other studies have linked childhood adversity to a large and diverse number of adult risk factors and health outcomes such as cardiovascular disease. To advance this literature, we undertook a broad examination of data from two linked surveys. The goal was to avoid retrospective distortion and to provide a descriptive overview of patterns of association. METHODS: A baseline interview for the Canadian National Longitudinal Study of Children and Youth collected information about childhood adversities affecting children aged 0-11 in 1994. The sampling procedures employed in a subsequent study called the National Population Health Survey (NPHS) made it possible to link n = 1977 of these respondents to follow-up data collected later when respondents were between the ages of 14 and 27. Outcomes included major depressive episodes (MDE), some risk factors and educational attainment. Cross-tabulations were used to examine these associations and adjusted estimates were made using the regression models. As the NPHS was a longitudinal study with multiple interviews, for most analyses generalized estimating equations (GEE) were used. As there were multiple exposures and outcomes, a statistical procedure to control the false discovery rate (Benjamini-Hochberg) was employed. RESULTS: Childhood adversities were consistently associated with a cluster of potentially related outcomes: MDE, psychotropic medication use and smoking. These outcomes may be related to one another since psychotropic medications are used in the treatment of major depression, and smoking is strongly associated with major depression. However, no consistent associations were observed for other outcomes examined: physical inactivity, excessive alcohol consumption, binge drinking or educational attainment. CONCLUSIONS: The conditions found to be the most strongly associated with childhood adversities were a cluster of outcomes that potentially share pathophysiological connections. Although prior literature has suggested that a very large number of adult outcomes, including physical inactivity and alcohol-related outcomes follow childhood adversity, this analysis suggests a degree of specificity with outcomes potentially related to depression. Some of the other reported adverse outcomes (e.g. those related to alcohol use, physical inactivity or more distal outcomes such as obesity and cardiovascular disease) may emerge later in life and in some cases may be secondary to depression, psychotropic medication use and smoking.

Addiction-related genes in gambling disorders: new insights from parallel human and pre-clinical models.

Neurobiological research supports the characterization of disordered gambling (DG) as a behavioral addiction. Recently, an animal model of gambling behavior was developed (rat gambling task, rGT), expanding the available tools to investigate DG neurobiology. We investigated whether rGT performance and associated risk gene expression in the rat's brain could provide cross-translational understanding of the neuromolecular mechanisms of addiction in DG. We genotyped tagSNPs (single-nucleotide polymorphisms) in 38 addiction-related genes in 400 DG and 345 non-DG subjects. Genes with P<0.1 in the human association analyses were selected to be investigated in the animal arm to determine whether their mRNA expression in rats was associated with the rat's performance on the rGT. In humans, DG was significantly associated with tagSNPs in DRD3 (rs167771) and CAMK2D (rs3815072). Our results suggest that age and gender might moderate the association between CAMK2D and DG. Moderation effects could not be investigated due to sample power. In the animal arm, only the association between rGT performance and Drd3 expression remained significant after Bonferroni correction for 59 brain regions. As male rats were used, gender effects could not be investigated. Our results corroborate previous findings reporting the involvement of DRD3 receptor in addictions. To our knowledge, the use of human genetics, pre-clinical models and gene expression as a cross-translation paradigm has not previously been attempted in the field of addictions. The cross-validation of human findings in animal models is crucial for improving the translation of basic research into clinical treatments, which could accelerate neurobiological and pharmacological investigations in addictions.

Retrospective and prospectively assessed childhood adversity in association with major depression, alcohol consumption and painful conditions.

BACKGROUND: Considerable evidence now links childhood adversity to a variety of adult health problems. Unfortunately, almost all of these studies have relied upon retrospective assessment of childhood events, creating a vulnerability to bias. In this study, we sought to examine three associations using data sources that allowed for both prospective and retrospective assessment of childhood events. METHODS: A 1994 national survey of children between the ages of 0 and 11 collected data from a 'person most knowledgeable' (usually the mother) about a child. It was possible to link data for n = 1977 of these respondents to data collected from the same people in a subsequent adult study. The latter survey included retrospective reports of childhood adversity. We examined three adult health outcomes in relation to prospectively and retrospectively assessed childhood adversity: major depressive episodes, excessive alcohol consumption and painful conditions. RESULTS: A strong association between childhood adversities (as assessed by both retrospective and prospective methods) and major depression was identified although the association with retrospective assessment was stronger. Weaker associations were found for painful conditions, but these did not depend on the method of assessment. Associations were not found for excessive alcohol consumption irrespective of the method of assessment. CONCLUSIONS: These findings help to allay concerns that associations between childhood adversities and health outcomes during adulthood are merely artefacts of recall bias. In this study, retrospective and prospective assessment strategies produced similar results.

Disordered gambling among higher-frequency gamblers: who is at risk?

BACKGROUND: When gambling opportunities are made available to the public in a given jurisdiction, some individuals participate occasionally and others more frequently. Among frequent gamblers, some individuals develop problematic involvement and some do not. This study addresses the association among demographic and social risk factors, frequency of gambling and gambling disorders. METHOD: Data from an adult community sample (n=1372) were used to identify risk factors for higher-frequency gambling and disordered gambling involvement. RESULTS: Individuals with higher intelligence, older individuals and more religious individuals were less frequent gamblers. Males, single individuals and those exposed to gambling environments (friends and family who gamble) and those who started to gamble at a younger age were more frequent gamblers. Excitement-seeking personality traits were also higher among more frequent gamblers. A different set of risk factors was associated with the likelihood of gambling disorder among these higher-frequency gamblers. These variables included mental health indicators, childhood maltreatment and parental gambling involvement. Among higher-frequency gamblers, individuals who smoke cigarettes, those with a diagnosis of alcohol or drug dependence or obsessive-compulsive disorder, those with higher anxiety or depression and those with higher impulsivity and antisocial personality traits were more likely to report gambling-related problems. These individuals were also more likely to report gambling on electronic gambling machines (e.g. slot machines). CONCLUSIONS: These data suggest a model in which higher-frequency gambling, particularly with electronic gambling machines, when combined with any type of emotional vulnerability increased the likelihood of gambling disorder.

Addiction, culture and family therapy strategies.

Τhis update reviews the empirical evidence supporting the use of couple and family therapies in managing families affected by addiction, both adolescent and adult populations. A particular focus of the paper is the need for a "culturally competent" strategy in assessing and treating target families.

Problem and pathological gambling in North American Aboriginal populations: a review of the empirical literature.

This literature review attempts to: estimate Aboriginal population prevalence rates for problem and pathological gambling and compare these rates to the general population; determine factors associated with the Aboriginal population problem gambling behaviour; and identify other salient findings and issues. Materials used in the review were drawn from available research literature and bibliographies. There were no time restrictions or study design criteria included in the review. Key words used: Aboriginal, Indians, First Nations, Native, lotteries, gambling, casinos, and gaming. Eleven descriptive studies were identified. Gambling appears to be problematic among Aboriginal people. Aboriginal adolescents have higher rates of problem gambling, as do Aboriginal adults for both problem and pathological gambling than their non-Aboriginal counterparts. The odds ratios indicate that the Aboriginal population has a problem gambling behaviour rate 2.2 to 15.69 times higher than the non-Aboriginal population. A number of factors associated with Aboriginal population problem and pathological gambling were identified. Gambling literature specific to the Aboriginal population is limited and there is extensive variation in estimates of their increased risk. Several associated factors were identified but whether these are specific to the Aboriginal population or to all problem and pathological gamblers needs to be determined. More research, particularly qualitative, into these factors is warranted.

Motivational enhancement and self-help treatments for problem gambling.

Two brief treatments for problem gambling were compared with a waiting-list control in a randomized trial. Eighty-four percent of participants (N = 102) reported a significant reduction in gambling over a 12-month follow-up period. Participants who received a motivational enhancement telephone intervention and a self-help workbook in the mail, but not those who received the workbook only, had better outcomes than participants in a 1-month waiting-list control. Participants who received the motivational interview and workbook showed better outcomes than those receiving the workbook only at 3- and 6-month follow-ups. At the 12-month follow-up, the advantage of the motivational interview and workbook condition was found only for participants with less severe gambling problems. Overall, these results support the effectiveness of a brief telephone and mail-based treatment for problem gambling.

Alcoholism: beliefs and attitudes among Canadian alcoholism treatment practitioners.

OBJECTIVES: To explore differences in views concerning adjunctive medications and theoretical orientation among Canadian practitioners from different professional backgrounds who treat alcoholism. METHODS: A survey of clinicians from different disciplines was conducted by mail. The response rate was 56%: 95 drug and alcohol counsellors, 46 social workers, 81 nonpsychiatrist addiction physicians, and 74 addiction psychiatrists. The number of items in the questionnaire was reduced using principal component analysis. Group differences were explored using analysis of variance with Bonferroni correction and Scheffé's posthoc comparisons. RESULTS: Physicians and nonphysicians differed in their views on the utility of medications in treating alcohol problems, the disease concept of alcohol problems, and the classification of alcohol abuse or dependence as psychiatric conditions. No group differences emerged on views regarding cognitive-behavioural treatment, pharmacological-only interventions, combined treatment, and recovery without treatment. Psychopathology in the alcoholic was significantly more likely to be considered as secondary to the use of alcohol by nonpsychiatrist physicians. Nonphysician practitioners viewed alcoholic behaviour as self-medication. CONCLUSIONS: Groups differed on questionnaire items concerning medication use and the disease concept of alcoholism. Agreement on several areas may facilitate bridging the gap across disciplines. The implications of these results are discussed.

Influence of depression and gender on smoking expectancies and temptations in alcoholics in early recovery.

PURPOSE: Rates of smoking are much higher among persons with alcohol problems and a history of depressive illness than persons without those disorders. Drug use in general may be motivated by outcome expectancies such as negative affective reduction and relaxation. Persons with a history of depression may smoke as a means of mood management. The role of outcome expectancies and major depression in maintaining smoking behavior in a high-risk group of smokers, such as recovering alcoholics, has not been thoroughly examined. METHODS: Using a cross-sectional design, 161 abstinent alcohol-dependent men and women who smoked were administered the Inventory to Diagnose Depression (IDD), a self-report instrument for assessing current and lifetime depression according to DSM-IV criteria, and measures of alcohol dependence, nicotine dependence, smoking motives, and situation-defined temptations to smoke. RESULTS: As expected, smoking motives and temptations were moderated by history of depression. Alcoholics with a history of depression were more likely to smoke with the expectancy of negative affect reduction than those with no prior major depression. Using multiple regression, negative affective reduction, addiction, and severity of past depression were the strongest predictors of current temptations to smoke. IMPLICATIONS: These results suggest that individuals with a combined history of alcoholism and major depression are at a high risk to use smoking as a means of mood enhancement.

Medical education in substance-related disorders: components and outcome.

AIMS: To analyze the process of acquisition by physicians of a body of knowledge and skills in the management of substance abuse. DESIGN: A comprehensive search of English-speaking literature was conducted over 20 years. Articles assessing the outcome of educational strategies in undergraduate, graduate and continuing medical education were examined to determine the targeted sample, the educational strategies involved and the outcomes assessed. FINDINGS: Nine studies in undergraduate education, 11 in graduate and 11 in continuing education met the inclusion criteria. They were generally difficult to compare in design, strategy and outcome analysis. Cognitive knowledge and behavioral skills appear to be easier to obtain compared to more complex attitudinal shifts. CONCLUSIONS: There is growing consensus in the selection of a combined didactic and interactive educational strategy but few empirical data as to the more cost-effective learning interventions. Training must be reinforced at regular intervals. While the expanding panoply of interventions available to physicians should enhance the perceptions of role legitimacy and treatment optimism, cohort studies across levels of education, specialty groups and across-substance and other addictive behaviors are required to determine cost-effective educational strategies.

Natural and treatment-assisted recovery from gambling problems: a comparison of resolved and active gamblers.

AIM: An exploratory study was conducted to understand the process of recovery from gambling problems. DESIGN: Media recruitment was used to identify a resolved (n = 43) and a comparison group of active pathological gamblers (n = 63). PARTICIPANTS: Participants showed evidence of significant problems related to gambling as well as high rates of co-morbid mood and substance use disorders. The median length of resolution was 14 months with a range of 6 weeks to 20 years. FINDINGS: Resolved gamblers reported a variety of reasons for quitting gambling, related mainly to emotional and financial factors. They did not experience a greater number of precipitating life events compared with active gamblers but did report an increase in positive and a decrease in negative life events in the year after resolution. Both resolved and active gamblers who had relatively more severe problems were more likely to have had treatment or self-help involvement, whereas those with less severe problems, if resolved, were "naturally recovered". CONCLUSIONS: The results support the need for a continuum of treatment options for problem gamblers and provide helpful information about recovery processes.

Methodological and clinical challenges in evaluating treatment outcome of substance-related disorders and comorbidity.

OBJECTIVE: To review the steps required to develop an outcome evaluation package and to report on the 12-month outcome of an integrated day program. METHOD: Based on the identification of salient outcome predictors, standardized instruments were selected. A cohort of 78 patients was assessed at the time of admission to the program, at discharge, and 3, 6, and 12 months afterward. RESULTS: Improvements were sustained over 1 year in all areas including treatment needs, quality of life, and readiness to change. CONCLUSIONS: The gap between the "cultures" of treatment and research must be narrowed. Following evidence of a program's general effectiveness through outcome monitoring, a randomized control design is optimal for specific interventions. The optimal length of follow-up depends on the perceived confounds.

Using measures of readiness to change in individuals with schizophrenia.

The literature suggests that substance abuse treatment for schizophrenia patients should consider both the patients' readiness for active treatment and matching phases of intervention with phases of the patient's acceptance of his or her dual problems. This study assessed the suitability of existing measures of "readiness to change" for use with individuals with schizophrenia. Outpatients (n = 39) with a diagnosis of schizophrenia and alcohol and/or drug dependency or abuse were given three measures to assess the stage of readiness to change. Results suggested that there was no agreement between stages defined by the interviewer and stages defined by self-report. This has implications for assessing readiness to change in terms of substance use in a population with schizophrenia.

Implications of depression on outcome from alcohol dependence: a 3-year prospective follow-up.

The prognostic implications of comorbid depression for outcome from alcohol dependence are unclear. It has been suggested that drinking may represent self-medication of depressive disorders and, alternatively, that the pharmacological properties of alcohol induce episodes of depression. In the present study, these questions were investigated by following 84 alcohol-dependent individuals seeking treatment (34% women) for 3 years in a naturalistic, prospective design. During the follow-up period, depressive and drinking outcomes were significantly related. However, there was no evidence that drinking reliably preceded depressive episodes or that depressive episodes precipitated heavy drinking. Despite their high co-occurrence, this study did not find evidence of a strong, direct causal relationship between these phenomena.

Group treatment for substance abuse in schizophrenia.

OBJECTIVES: A review of the relevant research suggests a need to develop an appropriate, effective, and replicable treatment to help individuals with schizophrenia and substance abuse problems. This pilot study describes a biweekly group specifically designed to help the individual with both schizophrenia and substance abuse. The components of the group were support, psychoeducation, and skills training. Attention was also paid to the stage of recovery. METHOD: Eighteen subjects attended the group and were assessed pregroup. Thirteen subjects completed a 1-year follow-up, and 5 subjects were assessed between 3 and 6 months. RESULTS: At the follow-up assessment, 8 subjects (44%) were abstinent. CONCLUSIONS: This type of treatment appears to be effective for reducing substance abuse in this population.

The epidemiology of cocaine and opiate abuse in urban Canada.

This study describes the epidemiology of cocaine and heroin abuse in urban Canada as part of an initial report on a national substance abuse surveillance system, the Canadian Community Epidemiology Network on Drug Use. Data pertaining to prevalence of use, law enforcement, treatment, morbidity and mortality of cocaine and heroin were obtained from the appropriate health and law enforcement institutions in six sentinel cities: Vancouver, Calgary, Winnipeg, Toronto, Montreal and Halifax. Cocaine and heroin appear to be more available in Vancouver than in the remaining cities. In all CCENDU cities, large proportions of persons in treatment programs for substance abuse identified cocaine as their major addiction; however, there is considerable variation in treatment utilization regarding heroin. Vancouver ranks first in terms of the per capita number of cocaine- and heroin-related hospital separations and mortality rate. Cocaine abuse appears to be an emerging problem in Calgary, Winnipeg and Halifax, and opiate abuse appears to be an emerging problem in Calgary.

Smoking cessation treatment for patients with schizophrenia.

OBJECTIVE: This study was an uncontrolled trial to assess the efficacy of a smoking cessation group program modified for individuals with schizophrenia. METHOD: Fifty outpatients with schizophrenia were divided into five groups who met separately for seven weekly sessions of a smoking cessation program. The subjects' schizophrenic and extrapyramidal symptoms were assessed before the group sessions began and after they had been completed. Assessments of smoking were made at those times and at 3-month and 6-month follow-ups. RESULTS: Forty-two percent of the subjects had stopped smoking at the end of the group sessions; 16% remained abstinent at 3 months, and 12% at 6 months. These changes were statistically significant. There was no change in the positive or negative symptoms of schizophrenia. CONCLUSIONS: The results suggest that it is possible for individuals with schizophrenia to stop smoking.

Substance abuse and the emergency room: programmatic implications.

A literature review (1984 to 1995) was conducted to identify cost effective policy implications regarding substance use in the emergency room (ER) and trauma unit. Prevalence rates, ranging from 9% to 47%, vary according to where, when and who is tested. Other drugs, most commonly marijuana, benzodiazepines and cocaine, follow a similar pattern to alcohol. The optimal method of measuring substance use depends on the goal of the assessment and a combination of clinical, self-report and biochemical markers is recommended. Simple screening questions such as the TWEAK or AUDIT should be routinely used with all attendants and further assessment provided only when high risk factors have been identified. These include: males, younger patients, metropolitan centres, after midnight and on weekends, injury from violence, accidents including MVAs, high acuity and psychiatric morbidity. Further, this screening should be complimented by an intervention, referral and treatment resource for those in need.