The mental status of 1090 heroin addicts at entry into treatment: should depression be considered a 'dual diagnosis'?

Drug addiction is definable as an illness [1] with core signs and symptoms (craving and relapsing behaviour) pertaining to the field of psychiatry and behavioural science [2]. Moreover, psychiatric symptoms are often prominent in states of intoxication and withdrawal, and presentations post-withdrawal are often characterised by persistent discomfort. Also, autonomous psychiatric impairment resulting from independent brain dispositions are often coupled to addiction, which makes the case one of dual diagnosis [3, 4]. On the whole, psychiatric symptoms are the rule rather than the exception among heroin addicts seeking any kind of treatment, but the symptomatology that we often attribute to a comorbid mental disorder may be sometimes just be a consequence of substance use and not actually indicative of the presence of an additive psychiatric disorder.

We pose the following questions: what psychiatric mental symptom clusters occur in heroin addiction, what is the prevalence of a depressive mental cluster, and what should be considered a genuine 'dual diagnosis'?

Our study aims to provide new information about: (1) the mental status of heroin addicts who apply for treatment of their opiate addiction, and (2) The degree of association of their baseline mental status with age, sex, substance abuse history, duration of dependence and other additive, autonomous psychiatric disorder(s) not falling into the category of substance use disorder (actual 'dual diagnosis').

Only 376 (34.5%) patients showed awareness of their illness, which means that this group conceptualise themselves as having a self-maintaining disease caused by previous exposure to heroin, and are in need of some long-term relapse prevention. A total of 499 (45.8%) reported depressed mood, and 437 (40.1%) report preoccupation with somatic functions or experience of spontaneous anxiety. Sleep disorders were reported by 374 subjects (34.3%), and (hypo)manic or mixed excitement was displayed in a prominent way by 262 (24.0%) patients at time of evaluation; 230 (21.1%) felt or showed aggressive behaviours and/or had been violent recently; 97 (8.9%) had engaged in self-injurious acts. Appetite was increased or decreased in 173 (15.9%) subjects. Memory disturbance occured in 139 (12.8%) subjects. The least featured symptoms were delusions (n = 76; 7.0%), altered states of consciousness (n = 70; 6.4%) and hallucinations (n = 51; 4.7%).

Significant gender-related differences for psychic impairment at treatment entrance were revealed by univariate analysis (Table 2). Females were more likely to display eating disturbances, states of anxiety, depression, violence, psychomotor excitement, suicidal thoughts and behaviours, and delusions. On the whole, women tended to have a higher level of psychic impairment at treatment initiation.

Principal component factor analysis of the selected 12 items of DAH-RS yielded a three-factor solution, with a loading greater than 0.40 (Table 3). The first factor reflects a 'depressive-anxious' dimension (illness awareness, anxiety state, depressed mood, sleep and eating disturbances), which accounted for 31.1% of the variance. The second factor, accounting for 11.9% of the variance, reflects a psychomotor excitement dimension (hypomanic/manic or mixed state, aggressiveness and violence, suicidality). The third factor, which reflects a 'psychotic state' dimension, included memory deficits, altered consciousness, delusions, and hallucinations, accounted for 10.3% of the total variance.

On the basis of the highest z-scores obtained for each factor (dominant factor) we clustered all the subjects into three groups. The dominant 'depressive-anxious' group comprised 506 subjects (46.4%), the dominant 'psychomotor excitement' group 421 (38.6%), and the dominant 'psychotic state' group 163 (15.0%). Comparison of these groups (Table 4) revealed significant differences.

Depressive-anxious heroin addicts had milder somatic impairment, abused fewer (other) substances, and underwent fewer types of treatment attempts. Their educational level was on the average lower, their economic conditions were better, heroin use was daily or less frequent for most, rather than 'more times a day' as in other groups. The addictive mode (i.e. the kind of lifestyle while using heroin) was typically the 'stable' one, that is maintaining productivity and not engaging in street crime despite major individual and relational impairment, common to all DAH-RS profiles. Nevertheless, the majority in this group had undergone a series of relapses and repeatedly failed to maintain abstinence (so-called 'revolving door stage'). The prevalence of concurrent use of alcohol, unprescribed benzodiazepines, cocaine and cannabis is lower. Social adjustment is impaired to a greater extent in dominant 'psychomotor excitement' patients. Lastly, dominant 'depressive-anxious' patients were less likely to be rated as having a 'dual diagnosis' by a more thorough psychiatric evaluation by means of DSM and SID. In other words, it can be stated that the global weight of addiction-related impairment is lower for dominant 'depressive-anxious', in comparison with dominant 'psychomotor excitement' or 'psychotic state' peers. Baseline conditions of dominant psychomotor excitement and psychosis are more likely to correspond to the otherwise assessed presence of an additive and autonomous psychiatric disorder (dual diagnosis).

A current major depressive episode has been reported in 16–34% of patients seeking treatment [11‐16], this percentage being higher than among those out of any treatment [17]. Females are more likely to have a current major depressive episode [17]. In our study the percentage of patients who were depressed when entering treatment (about 46%) is higher than what reported by other authors, and in particular about 50% of female patients are undergoing an episode of major depression. A similar percentage of patients (46%) fell into the dominant 'depressive-anxious' group, including depressed mood together with anxiety states, sleep disturbance and altered appetite. In our study, the depressive-anxious dimension, built in as a factor, is also the most represented (31.1% of total variance). However, the depressive-anxious factor isn't related to the severity of addiction history, nor it is strongly linked to the presence of a dual diagnosis.

The 'psychomotor excitement' dimension, also accounting for aggressiveness and self-injurious behaviour, is prominent for 38.62% of subjects. On clinical and psychopathological grounds, psychomotor excitement is usually related to the presence of dual diagnosis, with special regard to bipolar disorder. Of note, the prevalence of such a factor in our sample is far higher than previous literature rates of manic/hypomanic and mixed states, ranging from 0.1% [16, 18] to 5.5% [19, 20], but in the sub-sample recruited in our university psychiatric setting rates of bipolar I and II were even higher (51–55%) [21, 22]. Additionally, in our study dominant psychomotor excitement patients were more likely to be assessed as having a dual diagnosis than are dominant depressive-anxious patients. Subjects who present prominently as psychotic upon entering treatment are far more uncommon (14.9%) with regard to a factor accounting for delusion (7.0%) hallucinations (4.7%), memory disturbance (12.8%), or altered consciousness (6.4%). Other authors agreed, reporting low rates for psychosis among heroin addicts [23‐25], yet we found even lower rates. These subjects are also more likely to be affected by a dual diagnosis in comparison with depressive-anxious subjects. Lastly, in our sample, heroin-dependent patients tend to have poor illness awareness regardless of presence a true dual diagnosis.

Our data show that depressive features are the most frequent psychiatric symptoms among heroin addicts looking for treatment, and part of the most highly represented clinical state (depressive-anxious). However, the depressive features of heroin addicts are associated with anxiety rather than with suicidality, and a dominant depressive-anxious state is linked to a lower severity of drug addiction history. Conversely, psychomotor excitement and psychosis predict the presence of polysubstance abuse and an actual dual diagnosis. Therefore, it is very important for clinicians to be able to identify major as well as minor psychomotor excitement and psychotic symptoms in heroin addicts presenting for treatment, because it is likely that these patients are affected by another independent mental disorder (dual diagnosis) that deserves specific clinical attention and treatment. By contrast, the presence of depressive features in the clinical presentation of heroin addicts appears to be an unreliable indicator of general psychiatric severity and appears to be a common comorbid condition of the average addict, also developing at lower levels of addiction severity, along with the early course of the addictive disease. In conclusion, our data indicate something opposite to the general trend to identify dual diagnosis from baseline depression patients and ascribe psychomotor excitement or psychosis to intoxication from psychoactive substances: depressive-anxious symptoms are more likely to be parallel to addiction as a non-specific form of psychic disturbance, whereas psychomotor excitement and psychotic ones are likely to have dual diagnosis.