Association of psychiatric and substance use disorder comorbidity with cocaine dependence severity and treatment utilization in cocaine-dependent individuals
Introduction
Cocaine use is widespread, affecting as many as one in six adults across a wide range of socioeconomic strata and ethnocultural groups in the United States (Shaffer and Eber, 2002) and internationally (http://www.who.int/substance_abuse/facts/cocaine/en/ accessed May 15, 2008). Cocaine dependence, while less prevalent, may affect as many as 3% of the adult U.S. population (Shaffer and Eber, 2002) and is associated with substantial social, vocational, and medical impairment and healthcare and legal costs to the individual and society.
Cocaine use often is associated with psychiatric comorbidity, e.g., antisocial personality disorder (ASPD; 24%), major depressive disorder (MDD; 18%), posttraumatic stress disorder (PTSD; 12%) (Falck et al., 2004), and a three-fold risk of panic attacks (O’Brien et al., 2005). Studies have shown that almost half of patients in treatment for a cocaine use disorder may have comorbid ASPD (Carroll et al., 1997), one-third to one-half a history of PTSD (Back et al., 2000, Brady et al., 2004, Mills et al., 2005), and 20% an affective disorder (Carroll et al., 1997). ASPD (Arndt et al., 1994) and depression (Carroll et al., 1997, Ziedonis and Kosten, 1991) have been shown to be associated with poorer response to addiction or psychiatric treatment by cocaine-abusing or dependent adults. PTSD similarly has been shown to be associated with poorer response to addiction treatment by opiate dependent (Hien et al., 2000) and mixed substance use disorder (Ouimette et al., 2003) patients, including higher rates of cocaine use (Hien et al., 2000).
In addition to frequently being comorbid with substance use disorders (SUDs), psychiatric disorders may be associated with an increased severity of these disorders (Cacciola et al., 2001, Compton et al., 2005b, Kidorf et al., 2004, Mills et al., 2007, Skinstad and Swain, 2001, Watkins et al., 2004). Further, substance dependence disorders may be associated with increased severity of anxiety disorders such as agoraphobia and PTSD (Grant et al., 2006), major depressive disorder (MDD; Kandel et al., 2001, Kessler et al., 1994, Kessler et al., 2005, Regier et al., 1990), bipolar disorder (Cassidy et al., 2001, Kessler et al., 1994, Regier et al., 1990), and Cluster B personality disorders, especially antisocial personality disorder (ASPD; Kandel et al., 2001).
However, the relationship between psychiatric and SUD comorbidity and illness severity and impairment is not necessarily consistent across domains of illness severity and impairment and may be the result of multiple concurrent psychiatric disorders rather than a single comorbid psychiatric disorder. For example, Mills et al. (2007) reported that opiate dependent treatment recipients with PTSD (compared to those who did not meet criteria for PTSD) were less likely to be employed, more impaired physically and psychosocially, and more likely to have a history of overdose or suicidality; but they also reported using heroin less frequently in the past month, reduced heroin use as successfully, and did not report higher levels of other drug use. Participants with PTSD in the Mills et al. (2007) study also were 1.6–2.5 times more likely than those without PTSD to meet criteria for major depression, ASPD, and borderline personality disorder as well as PTSD. Another study of opiate dependent treatment recipients found that PTSD was associated with a longer history of drug use and more severe psychiatric symptoms than patients not diagnosed with PTSD, but comparable reductions in heroin, cocaine, and alcohol use and better treatment attendance and retention (Trafton et al., 2006).
Given the serious morbidity and costs of cocaine dependence, this study was designed to examine the relationship to severity of cocaine dependence of both specific comorbid psychiatric disorders and the added burden that may occur when multiple comorbid psychiatric disorders are present. Although the study's focus was on psychiatric comorbidity and cocaine dependence, the presence of other substance dependence diagnoses also was assessed. Symptom severity and psychosocial impairment tend to be heightened with polysubstance dependence, as well as the risk of exposure to traumatic stressors, PTSD, and other psychiatric morbidity (Salgado et al., 2007). Therefore, it is important to distinguish between the effects of psychiatric versus SUD comorbidity when examining potential correlates of cocaine dependence severity.
The rationale for focusing on the severity of cocaine dependence is that there is a nascent research literature showing potential relationships between psychiatric or SUD comorbidity and SUD severity. MDD was associated with risky behavior and cocaine use in a community study (Wild et al., 2005). In a clinical sample, bipolar disorder co-occurred commonly with substance use disorder, with an increased likelihood of mixed and rapid cycling mania, a chronic clinical course, medical disorders including liver disease, and both suicide attempts and completed suicides (Krishnan, 2005). PTSD has been associated with suicide attempts; co-occurring mood, anxiety, and personality disorder; overall psychiatric morbidity; family and social problems; marital violence; self-reported employment problems; and the number of episodes of substance abuse treatment—in both treatment samples (Back et al., 2000, Tarrier and Sommerfield, 2003, Wasserman et al., 1997) and non-treatment samples (Parrott et al., 2003, Thevos et al., 1993). ASPD also has been shown to be related to the severity of alcohol, psychiatric, and legal problems and risky sexual behavior among cocaine-abusing research treatment recipients (Ladd and Petry, 2003) and of SUD symptoms in community samples (Goldstein et al., 2007).
However, no study has examined the relationship of psychiatric and SUD comorbidity specifically with cocaine dependence severity, nor across a range of psychiatric disorders and a range of indices of impairment. Studies show evidence of more social, vocational, and legal problems when psychiatric disorders co-occur with cocaine dependence than with alcohol dependence (Brady et al., 2004, Thevos et al., 1993), suggesting that psychiatric morbidity may be particularly related to exacerbated symptom severity or impairment in cocaine dependence. In the present study, cocaine dependency severity was operationalized by specific indices that are consistent with the DSM-IV (American Psychiatric Association, 1994) criteria for substance dependence and psychometric measures of dependence severity (Miele et al., 2000), i.e., the number of withdrawal symptoms and of other dependence symptoms (Sofuoglu et al., 2003). In addition, other measures were used to characterize the increasingly heavy and dangerous use over a long time period that occurs when dependence is severe (i.e., number of days during the period of heaviest cocaine use ever; age of first heavy use of cocaine; history of overdoses). A criterion feature of substance abuse, adverse legal consequences (i.e., arrest related to cocaine use), was included because of the severe impact of involvement in the criminal justice system.
A second objective of the present study was to examine the association of psychiatric and SUD comorbidity with the utilization of treatment and self-help for cocaine dependence. The severity of cocaine dependence (Kampman et al., 2004) and mental distress (Dennis et al., 2005) has been associated with SUD treatment outcomes. However, the role of psychiatric comorbidity in the utilization of SUD treatment services has not been well studied (Chassler et al., 2006, Grella et al., 2003, Hansen et al., 2004, Van Ness et al., 2004). Cocaine or alcohol dependence severity at entry to SUD treatment has been shown to be associated with less treatment use in the next 6 months (Carpenter et al., 2002), but the only study examining psychiatric comorbidity found that PTSD was associated with more treatment use and retention (Trafton et al., 2006). The present study was designed to extend those findings by being the first, to our knowledge, to test the relationship between a range of psychiatric comorbidities and SUD treatment utilization.
Although self-help support program participation has been associated with sustained recovery from SUDs (Staines et al., 2003), few robust predictors of the use of self-help programs have been identified in past studies with individuals with SUDs (Carpenter et al., 2002, Weiss et al., 2000). Studies of cocaine-dependent individuals have shown that the severity of substance dependence is associated with self-help program attendance (Carpenter et al., 2002, Weiss et al., 2000), and suggest that cocaine-dependent persons without a religious preference may be inclined to attend self-help programs (Weiss et al., 2000). These studies primarily involved treatment-seeking persons, and have not examined psychiatric diagnoses as a potential correlate of self-help program participation. Therefore, this study also serves as a first test of the relationship of psychiatric comorbidity to SUD self-help support program attendance.
The study's two hypotheses were that, among cocaine-dependent adults, after controlling for the effects of demographics and lifetime history of co-occurring substance dependence diagnoses, a history of one or more psychiatric disorders would be associated with: (1) greater cocaine dependence severity, and (2) a higher likelihood of utilization of cocaine-related treatment and participation in SUD self-help groups. To the extent that psychiatric morbidity is associated with increased cocaine dependence severity (Hypothesis 1), the findings of Carpenter et al. (2002) suggest that psychiatric comorbidity may be associated with less treatment use. However, Trafton et al.'s (2006) specific finding of increased SUD treatment use by patients with PTSD, along with the generally positive association between psychological distress and SUD self-help participation, support the hypothesis of a positive relationship between psychiatric comorbidity and SUD treatment or self-help utilization. The present study also extends the research literature on predictors of SUD treatment or self-help utilization by assessing utilization as a dichotomous variable, i.e., whether treatment or self-help were used at all, rather than the prior studies’ focus on the amount of treatment or self-help utilization.
Section snippets
Participants and recruitment
The sample was drawn from a cohort of pairs of adult siblings who were cocaine-dependent and recruited to participate in genetic linkage studies of cocaine (Gelernter et al., 2005) or opioid dependence (Gelernter et al., 2006). Probands and siblings were recruited at the University of Connecticut Health Center (Farmington, CT); Yale University School of Medicine (APT Foundation; New Haven, CT); Harvard Medical School (McLean Hospital; Belmont, MA); and the Medical University of South Carolina
Results
Results of the multivariate GEE analyses are reported in Table 2 for variables reflecting the severity of cocaine dependence, and Table 3 for treatment or self-help participation variables.
Discussion
In this sample of cocaine-dependent adults who were recruited as sibling pairs for a genetics study, contrary to Hypothesis 1, psychiatric comorbidity was associated increased severity of cocaine dependence on only one of six cocaine dependence severity indices: “Days of Use in the Heaviest Period of Use.” However, consistent with Hypothesis 2, several psychiatric disorders were associated with an increased likelihood of participation in cocaine dependence treatment or self-help programs. These
Author disclosures
Funding for this study was provided by NIH grants R01 DA12849, R01 DA12690, K24 DA15105, K24 DA02288, and K24 AA13736. NIH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Author contributions
Gelernter, Kranzler, and Farrer designed the study and wrote the protocol. Gelernter, Kranzler, Weiss, and Brady oversaw recruitment and assessment of subjects. Farrer oversaw the development and maintenance of the database. Ford and DeVoe managed the literature searches and summaries of previous related work. Zhang, Ford, and Kranzler undertook the statistical analysis, and Ford wrote the first draft of the manuscript. All authors reviewed the manuscript for scientific content and approved the
Conflict of interest
None for any of the authors.
Acknowledgement
The authors thank Ms. Amy Stomsky for assistance in the preparation of the manuscript.
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