[Methodological problems of depression research]. / Metodeproblemer i depressionsforskningen.

Controlled clinical trials on the effect of the new antidepressive drugs are encumbered by a number of methodological weaknesses, one of which is lack of placebo control in many studies. The main problem in research into depression is, however, the overlooked issue of how to validate the diagnosis of depression. The agreed diagnostic inclusion criteria in these studies are the diagnostic criteria from the DSM-III or the ICD-10. These disease classifications are in accordance with what has been called the epidemiological disease model. The conclusions of all clinical trials are, however, based on the assumption of a different disease model, the bio-medical disease model. There has truly been a documented effect of these drugs in controlled clinical trials of groups of patients diagnosed with depression, but this conclusion is not stronger than the validity of the diagnosis of depression itself. The categorization of antidepressive drugs as drugs with antidepressive effect has a similar basis even if these drugs were introduced on the basis of a theory of the neurobiology of depression. It is therefore perhaps unclear what has really been documented in these studies. The time has come for a closer inspection of how to use the controlled clinical trial in the field of depression, as well as for a discussion and clarification of what we mean when we use the diagnosis of depression.

[Naltrexone. An opioid antagonist to support the drug-free state in previous opioid addicts having stopped the habit]. / Naltrexon. En opioidantagonist til understøttelse af stoffrihed hos afvaennede, tidligere opioidafhaengige.

Naltrexon (Nemexin) is an opioid antagonist for oral use and with a relatively long duration time. The preparation is valuable as supplementary therapy for maintenance of the drug-free state in previous opioid addicts who have broken the habit. Clinical use requires thus that the patient is completely detoxified from opioids. Prior to commencement of the first dose of naltrexon, a drug-free period of seven to ten days is recommended. The drug-free state may be verified by screening of the urine or a trial injection of naloxon. The detoxification/drug-free phase may be abbreviated by combined treatment with clonidine and naltrexon. Following the detoxification and drug-free phase, naltrexon therapy is initiated with the half dose (25 mg) on the first day and continued with 50 mg daily. The preparation should not be given to pregnant women or women who are breast-feeding, to children under the age of 18 years or to patients with renal failure. Liver enzyme control tests should be carried out before and during treatment. The number of side-effects reported are few. In clinical investigations, naltrexon has proved to be valuable in a significant minority of opioid dependent patients investigated. Utility is increased with the patients' motivation for this form of treatment. The success rate for naltrexon supportive treatment measured by retention in the therapeutic programme is higher than for traditional drug-free treatment but lower than for methadone supported treatment. Effects on the risk of relapse in the long run have not been documented.

[HIV-positive drug addicts treated at the Copenhagen City Drug Dependency Clinic 1986-1992]. / HIV-smittede stofmisbrugere behandlet ved Københavns Kommunes Ambulatorium for Stofmisbrugere 1986-1992.

The Copenhagen City Drug Dependency Clinic at the former Rudolph Bergh's Hospital was established in 1986 as part of the measures taken by the municipality of Copenhagen to control the spread of HIV/AIDS among the intravenous drug addicts in the City of Copenhagen. The aim was to attract those HIV-positive drug addicts who were in no formal treatment for their drug addiction at other treatment centres and to retain them in treatment for a longer period acknowledging the fact that no causal cure exists for either the drug addiction or for AIDS. The goal of the treatment was to reduce HIV-risk behaviour i.e. sharing needles and syringes and unprotected sex with multiple partners and to reduce the adverse medical and social consequences of continued drug abuse. The treatment was supported by methadone treatment. During the five year period of 1986-92 a total of 196 HIV-positive drug addicts were referred to the clinic. A little more than half of those referred for the first through the third time and five out of six referred for the fourth time were admitted to treatment at the clinic. Half of the 126 first-time treated patients were retained in treatment for up to one year, while the rest were retained in treatment from one to five years. The mean time spent in treatment at the clinic was shorter for the relatively few patients who were admitted for the second time than for those admitted for the first time. At the end of the study 39 patients (20%) had died, most of them for non-AIDS related reasons.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug-use pattern, comorbid psychosis and mortality in people with a history of opioid addiction.

OBJECTIVE: To compare the 15-year mortality of people with a history of opioid dependence that had achieved stable abstinence, with the mortality associated with continued drug use. Another objective was to study the influence of hospitalization with comorbid psychosis on the 15-year mortality. METHOD: In 1984, 188 persons (122 men and 66 women) with a history of intravenous narcotics addiction were interviewed about their drug-use pattern. A registry-based follow-up continued through 1999 and mortality was assessed. Three 1984-drug-use categories were formed. In category 1, cohort members had achieved stable abstinence from drug use by 1984. Using Cox multiple regression analysis, we (i) estimated reduced mortality of category 1 drug users, and (ii) studied the influence of hospitalization with comorbid psychosis on mortality. RESULTS: About 32% had died during the 15-year follow-up. The 15-year mortality associated with stable abstinence was reduced by 56% when compared with the perceived worst drug-use pattern. Hospitalization for comorbid psychosis was not independently associated with mortality in this sample. When drug-use categories were compared with mortality expectations for the general population, the standard mortality rates (SMRs) were clearly elevated. Even in the stably abstinent drug-use category (category 1), SMR was significantly elevated by at least seven-fold in both genders. CONCLUSION: People who had achieved stable abstinence from injecting narcotics use were at lower risk of premature death than people with continued drug use. A residual observed excess mortality in people who had apparently achieved stable abstinence from drug use is consistent with the view of drug addiction as a chronic disease.

[Scientific theory and drug abuse research]. / Videnskabsteori og misbrugsforskning.

Scientific medicine has for years been faced with the classical philosophical dilemma between ontological realism and epistemological empiricism. The impact of this dilemma is especially important in scientific psychiatry and, not least, in the study of substance use disorders. Much controversy exists concerning the question of what psychiatric diseases "really are" and how disease should be separated from non-disease. The anti-psychiatric movement claimed that the disease model in psychiatry should be totally abandoned, and the impact of this movement on our daily thinking may have been greater than we have generally recognized. As for the substance use disorders there is no doubt that the disease model is generally considered no use. But giving up the disease model--or one of the disease models--has serious consequences for the scientific study of these disorders. The interpretation of data from eg a long-term follow-up study of substance users is impossible except in a disease-model frame-of-reference. So is any search for causes or search for effects of a certain treatment. Usually an explicit discussion of the philosophical frame-of-reference in such studies is not given with the consequence that scientific discussions of substance use or substance use disorders are often waste of time.

Seven year follow-up of 300 young drug abusers.

300 young morphine addicts in Copenhagen were personally followed up 7 years after their first referral for treatment. The tracking rate was 93.7%. Of the original population, approximately 2% died yearly, i.e. 16%. Each year 5-6% ceased drug abuse, and in 1980, 39% were characterized as being socially well adjusted. In all, 20% remained heavy drug users, though some had changed to other drugs.

Eleven year follow-up of 300 young opioid addicts.

A cohort of 300 young opioid addicts (203 male and 97 female) attending the City of Copenhagen Drug Treatment Service (200) or the Nordvang Hospital (100) for first-time treatment during 1973 was personally followed up in 1980 and 1984. In both studies about 90% were traced. Outcome was classified on a four-step scale according to current drug status and occupational status. In 1984 24% of the cohort were classified in the best outcome class while 26% were dead, yielding an average mortality of 2.4% per year. Sixteen per cent were classified as substance users, including persons mostly abusing alcohol or tranquilizers. In contrast to our predictions in 1980 the number of persons achieving stable abstinence does not turn out to be steadily increasing with time. The number of active drug addicts declines mainly because they die, not because they achieve abstinence. According to more strict criteria less than 20% would be classified as truly recovered. Another 5 - 10% achieve some unstable abstinence. The long-term prognosis seems to be highly unfavourable for the study population as a whole.

Peptic ulcer complaints in lithium-treated and non-lithium-treated manic-depressive patients.

A possible protective effect of lithium against the occurrence of peptic ulcer complaints in manic-depressive patients, treated with lithium, was investigated. 167 manic-depressive patients, 91 in lithium treatment, 76 not in lithium treatment, were questioned about clinical symptoms of peptic ulcer. Thirteen of the lithium-treated and 23 of the non-lithium-treated patients reported symptoms of peptic ulcer. The difference was statistically significant. The hypothesis that lithium treatment reduces the frequency of symptoms of peptic ulcer in manic-depressive patients was thus confirmed.

The use of case vignettes in studies of interrater reliability of psychiatric target syndromes and diagnoses. A comparison of ICD-8, ICD-10 and DSM-III.

This study is part of the ICD-10 field trials in which the use of case vignettes for interrater agreement has been examined. From our electronic database of 880 consecutively admitted inpatients we selected 24 cases that were transcribed to vignettes covering the first 5 ICD-10 target syndrome of dementia, substance use disorders, schizophrenia, mood and anxiety disorders. ICD-10 was compared with ICD-8 and DSM-III. The results showed that all 3 standard classification systems obtained an acceptable interrater agreement. Among the diagnoses, depressive disorders gave rise to most disagreement between the raters. Discrepancies between the methods of measuring interrater agreement were found when intraclass reliability was compared with consensus calculations for the individual patient.

Integration of DSM-III and ICD-8 to be used in a consultation-liaison psychiatric service. Preliminary experiences.

In 1983 a total of 405 patients received psychiatric supervision in somatic departments in the general hospital. At this supervision, these patients were registered by means of a five-axial diagnostic coding according to the DMS III principle, and this was combined with a quantitative global assessment of the severity of the condition. Reliability testing was undertaken by five supervising physicians with a total of 15 patients. The total number of supervisions constituted one supervision per somatic bed per annum. Women were overrepresented, and medical departments made the greatest use of psychiatric supervision. Reactive conditions dominated parallel with a high relative incidence of alcohol-related conditions. In patients with diagnoses of psychoses, only slight to moderate psychiatric symptoms were encountered. This held true also for personality deviations. 50% of the patients had experienced significant psychosocial stress, but 10% of these were diagnosed as having non-reactive psychoses, 52% of the patients had moderate to pronounced disturbances of social function. Half of the patients supervised in this manner could be investigated or treated in the referring departments. Approximately half of the patients in whom referral to private psychiatric specialists was made did not keep these appointments. Reliability testing in the material shows the employability of the diagnostic armamentarium. All in all, the investigation suggests that extension of the liaison psychiatric service in somatic departments would result in a relative increase in the number of patients who could be treated in the referring department and an increase in the number of psychiatric conditions diagnosed. Establishment of a psychiatric outpatient clinic in the somatic environment appears to be indicated.