The prevalence of psychiatric disorders in patients with alcohol and other drug problems.

A survey evaluated the lifetime and current prevalence of mental disorders in 501 patients seeking assistance with alcohol and other drug problems at an addiction research and treatment facility. Information was gathered using the National Institute of Mental Health Diagnostic Interview Schedule (DIS) and computer diagnoses were generated according to DSM-III criteria. Four fifths (78%) of the sample had a DIS lifetime psychiatric disorder in addition to substance use, and two thirds (65%) had a current DIS mental disorder. Excluding the unreliably diagnosed generalized anxiety disorder, the most common lifetime disorders were antisocial personality disorder, phobias, psychosexual dysfunctions, major depression, and dysthymia. Patients who abused both alcohol and other drugs were the most psychiatrically impaired. Patients with DIS psychiatric disorders had more severe alcohol and other drug problems. Barbiturate/sedative/hypnotic, amphetamine, and alcohol abusers were the most likely to have a DIS mental disorder.

Slouching toward a systems approach to treatment.

Both the health care sector generally and the alcohol and drug field are moving toward a truly systematic approach to treatment, accelerated by the anticipated advent of health care reform. There is considerable reluctance to develop systems. Many are not convinced of their necessity, and systematization inevitably involves a decrement in autonomy for the components of the system. Nor are systems panaceas; they have problems of their own, such as the bottleneck. But only true systems will be able to cope with the expected increase in demand for services that will accompany the universal entitlement of health care reform. Recent work giving the alcohol and drug treatment field an edge in systems development is discussed. Regrettably, the main motivation for deploying systems has become economic. They would more appropriately be justified by their potential for enhancing the efficacy of treatment.

Relationship between treatment facilities and prevalence of alcoholism and drug abuse.

Data are presented which suggest that, in the Commonwealth of Pennsylvania, the availability of treatment of drug abuse and alcoholism is inversely related to the prevalence of the problems. It is hypothesized that as the treatment response to one increases, the treatment response to the other declines. Some of the possible causes and consequences are outlined.

Use of the life table method in determining attrition from treatment.

Life table analysis of attendance at an outpatient clinic indicates levels of attrition similar to those reported by follow-up and other studies of treatment for drug dependence. With appropriate qualifications, rates of attrition may be viewed as measures of treatment outcome.

Alcohol and drug problems: a challenge to consultation-liaison psychiatry.

Although alcohol and drug problems are prevalent in the population at large and among patients in general hospitals, they have not been a major concern of consultation-liaison psychiatry. A setting in which all psychiatric consultations are directed to such problems, the Clinical Institute of the Addiction Research Foundation, is described, and parameters of its consultation experience are explored. It is suggested that dealing with alcohol and drug problems should become an integral aspect of consultation-liaison psychiatry. Such a development may prove to be especially fruitful in teaching a comprehensive approach to patient care.

Psychiatric screening of alcohol and drug patients: the validity of the GHQ-60.

The 60-item General Health Questionnaire (GHQ) and the National Institute of Mental Health Diagnostic Interview Schedule (DIS) were administered to 501 patients presenting for assessment or treatment of alcohol or drug problems at the Addiction Research Foundation, Toronto, Canada. The GHQ proved to be a useful, if limited, instrument for routine screening for psychiatric disorders other than substance abuse in this population. The sensitivity or "utility" of the test at the optimum threshold score was considerably lower in this sample than in medical or community samples. Receiver Operating Characteristic (ROC) analysis suggests a need for an upward revision of the cut-off score to 23/24 inpatients with alcohol or drug problems. At this threshold, sensitivity was 69%, specificity 75%, positive predictive value 77%, negative predictive value 66%, and overall misclassification rate 29%. A definition of "caseness" was used that included all DIS Axis I disorders with the exception of substance use and "cognitive impairment." Sensitivity of the GHQ was highest for the affective disorders (79%). False negatives accounted for the bulk (61%) of the misclassification rate. At the threshold score of 23/24, positive predictive values were greater for the unemployed and for patients with either no current substance use disorder or with both alcohol and drug disorders.

The ethics and safety of alcohol administration in the experimental setting to individuals who have chronic, severe alcohol problems.

There is a popular belief that the experimental administration of alcohol to individuals who have chronic, severe alcohol problems ('alcoholics') is inherently dangerous or unethical. This creates an environment in which researchers who desire to conduct a study involving the administration of alcohol to persons with severe alcohol problems must defend the relative safety and reasonableness of this practice when, in fact, scientific justification for not using this important methodologic technique in alcohol research is lacking. The primary purpose of this manuscript is to present and discuss the safety, ethical, and practical considerations of research involving administration of alcohol to subjects who have had difficulty refraining from harmful alcohol use in the natural setting. The authors also describe a study in which they monitored the short-term effects of administering 0.4-0.6 g/kg alcohol to 16 recently abstinent subjects who had chronic, severe alcohol problems. This study revealed no evidence that the administration of beverage alcohol in the experimental setting to such individuals causes an uncontrollable desire for more alcohol, precipitates immediate relapse, or creates any behavioral problems. The data also suggested that the knowledge gained from the effects of alcohol ingestion in the experimental setting might help many subjects to understand more completely their addiction or drinking behaviour. It is concluded that there is no overriding reason why alcohol cannot, with due precaution, be safely and ethically administered in the experimental setting to human subjects who suffer from alcohol problems.

Alcohol and drug problems in ontario physicians: characteristics of the physician sample.

Thirty-six Ontario physicians who entered a treatment process for alcohol and drug problems were systematically assessed prior to treatment. The demographic and medical practice characteristics of this sample are delineated and, where possible, are compared to those of all Ontario physicians. Physicians with alcohol and drug problems were both similar to and different from all Ontario physicians. Further study is needed to explore the similarities and differences between the two groups, with a view to improving treatment, prevention and professional goverance.

Obsessive and compulsive characteristics of alcohol abuse and dependence: quantification by a newly developed questionnaire.

The purpose of the this study was to develop an instrument for measuring the obsessive and compulsive characteristics of drinking-related thought and behavior in subjects who abuse or are dependent on alcohol, and to quantify the extent to which drinking-related thought and behavior in these subjects resemble the obsessions and compulsions seen in obsessive-compulsive disorder (OCD). To achieve these goals, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was modified to reflect obsessionality and compulsivity specifically related to heavy drinking rather than to obsessions and compulsions generally. The modified Y-BOCS (Y-BOCS-hd) was administered to 62 subjects satisfying DSM-III-R criteria for alcohol abuse or alcohol dependence and 62 matched normal controls. The data showed that the Y-BOCS-hd is a sensitive and specific instrument for measuring the obsessive and compulsive characteristics of drinking-related thought and behavior in alcohol-abusing and alcohol-dependent populations, and that there are specific and quantifiable similarities between these characteristics and the obsessions and compulsions of OCD. The data also indicated that the Y-BOCS-hd may be a useful screening instrument for the presence of alcohol abuse and dependence.

Obsessive and compulsive characteristics of craving for alcohol in alcohol abuse and dependence.

The purpose of this study was to quantify the extent to which subjective ratings of craving for alcohol in the alcohol-abusing or dependent person (herein, alcoholic) correlate with measurable and specific characteristics of obsessions and compulsions. The Yale-Brown Obsessive Compulsive Scale modified to reflect obsessionality and compulsivity specifically related to heavy drinking (Y-BOCS-hd) was used for this purpose. Highly significant correlations were found in the alcoholic population (n = 62) between subjectively rated craving for alcoholic beverages and several of the Y-BOCS-hd questions regarding alcohol-related thoughts and drinking behavior. Additionally, mean craving scores were considerably greater in the alcoholic population than in the matched control population (n = 62). The data suggest that craving shares specific features in common with the obsessions of obsessive-compulsive disorder and that the existence of craving is dependent on the presence of obsessive thoughts about drinking. Positive correlations between craving and measures of compulsive drinking behavior also were found; compulsive drinking behavior, however, may reflect the consequences of craving rather than a fundamental characteristic of craving itself. The data show that despite difficulties in defining the term craving, it is clearly a phenomenon that is experienced or endorsed by most alcoholic subjects and is not by most persons who do not abuse alcohol.

Effect of haloperidol on measures of craving and impaired control in alcoholic subjects.

We recently proposed that alcoholics suffer from a functional defect within the basal ganglia/limbic striatum or its modulation by dopaminergic projections from the ventral tegmentum, and that inhibition of striatal output caused by the prodopaminergic effects of alcohol ingestion induces or exacerbates craving and impaired control over alcohol consumption in alcoholic individuals. To test this hypothesis, 16 subjects with a diagnosis of alcohol dependence or abuse were studied in a double-blind, placebo-controlled experiment in which the effects of the D-2 antagonist haloperidol on measures of craving and impaired control were assessed before and after administration of a priming dose of alcohol. Subjects were pretreated with 0.015-0.025 mg/kg haloperidol (experimental condition) or 2 ml normal saline (control condition), and subsequently consumed 0.4-0.6 g/kg ethanol as their preferred alcohol-containing beverage. Significant increases in subjectively rated craving for alcohol and perceived difficulty resisting additional alcohol consumption occurred following the priming dose of alcohol when subjects were pretreated with saline. In contrast, no significant changes in reported ability to resist additional alcohol occurred when subjects were pretreated with haloperidol, and reported levels of craving decreased relative to baseline following haloperidol pretreatment. Subjects also consumed about 25% less optionally available alcohol when pretreated with haloperidol than when pretreated with saline. These findings support the hypothesis that craving and impaired control are induced or exacerbated by the prodopaminergic effects of alcohol consumption.

Components of care for patients with schizophrenia.

To assist in the planning of mental health services for Metropolitan Toronto, the Mental Health Care Committee of the Metropolitan Toronto District Health Council convened a Task Force on Mental Health Epidemiology to help determine the need for services for patients suffering from schizophrenia. As part of its work, the Task Force described components of care which comprise a comprehensive treatment model. Underlying this approach was the recognition that many efficient, effective interventions for the treatment of schizophrenia have been developed and evaluated, but few attempts have been made to apply these various interventions in a systematic, comprehensive manner. This report presents an inventory of state-of-the-art approaches to dealing with schizophrenia which should be of interest both to practicing clinicians and health care planners.