Cigarette smoking in the early course of bipolar disorder: association with ages-at-onset of alcohol and marijuana use

Objectives: Despite the high prevalence of smoking among individuals with bipolar disorder, few studies have attempted to identify correlates of smoking status in this group. We examined illness characteristics of bipolar disorder as well as co-occurring alcohol and marijuana use as correlates of cigarette smoking, including the developmental timing of the onset of regular alcohol and cannabis use (i.e., three or more times per week for a month or more). Methods: Demographic and clinical characteristics of 134 patients with bipolar I disorder, the majority of whom were adolescents, who were hospitalized for their first manic episode were analyzed to identify correlates of smoking status. Results: A total of 61 (45.5%) of the patients were smokers at the time of their first hospitalization. Smokers were significantly more likely than nonsmokers to report recent use of marijuana (55.7% versus 18.1%) and alcohol (67.2% versus 25.4%). Among those who had ever used marijuana (48.5%) or alcohol (45.5%) regularly, current cigarette smokers reported a significantly earlier age-at-onset of regular use of both substances than reported by nonsmokers. Earlier age-at-onset of marijuana use was the only significant predictor of current smoking in a multivariate analysis. None of the bipolar disorder characteristics examined (i.e., symptom severity, age-at-onset of illness, rapid cycling, and psychosis) were correlated with smoking status. Conclusions: Smoking status in the early course of bipolar disorder is related to both current and past alcohol and marijuana use, but not to characteristics of bipolar illness. Earlier initiation of regular marijuana use is associated with an increased risk of smoking cigarettes.     

The natural history of alcohol abuse: implications for definitions of alcohol use disorders

Is the DSM-III-R category of alcohol abuse validly differentiated from the DSM-III-R category of alcohol dependence, or is abuse primarily a mild, prodromal condition that typically deteriorates into dependence? A 4-year longitudinal epidemiologic study of male drinkers provided data to answer this question. The study used identical questions at baseline and follow-up. At follow-up, 70% of the subjects who were initially classified as alcohol abusers were still abusers or were classified as remitted. This contrasted significantly with outcome in the subjects who initially reported alcohol dependence. Although additional research is needed, these results indicate that alcohol abuse often has a course distinct from that of alcohol dependence.     

Adolescent marijuana use: risk factors and implications

A sample of 1,270 students in Years 7, 10 and 11 attending seven State high schools in a middle class area of Sydney answered a self-report questionnaire designed to measure many aspects of their family situation, school performance, spare time activities, drinking and drug taking behaviour and sexual activity. Data on the reported prevalence of marijuana use and the variables significantly associated with marijuana use are presented and discussed. Marijuana use was reported by 4.2% of 12 year olds (Year 7), 26.5% of 15 year olds (Year 10) and 26.7% of 16 year olds (Year 11). More than half of those who had ever used marijuana had used it during the week prior to the survey and there were no significant differences in the characteristics between these recent and the remaining users. Marijuana users reported significantly poorer family relationships than non-users and were about twice as likely as non-users to come from a broken home and/or to have a mother who works full-time, which is often a consequence of marital break-up. Marijuana users also displayed poorer school performance, spent less time on homework and had more school absenteeism than non-users. Marijuana users were more than three times as likely as non-users to have had heterosexual intercourse, drunk alcohol 3 or more times in the past week and to smoke cigarettes. Also, the reported use of stimulants, hallucinogens, narcotics (heroin) and sedatives was almost entirely restricted to those who reported marijuana use. Improvements in the quality of family life may prevent the use of marijuana and other probably more harmful drugs, as well as the indulgence in other acting-out behaviours.     

Development of stimulus material for research in alcohol use disorders

The availability of appropriate stimulus material is a key concern for an experimental approach to research on alcohol use disorders (AUDs). A large number of such stimuli are necessary to evoke relevant alcohol‐related associations. We report the development of a large stimulus database consisting of 457 pictures of alcoholic beverages and 398 pictures of neutral objects. These stimuli were rated by 18 inpatients hospitalized due to severe AUD and 18 healthy controls along four dimensions: arousal, valence, alcohol‐relatedness, and craving. Physical parameters of the pictures were assessed. After outlier removal, 831 stimuli that were characterized as either alcohol‐related or neutral were retained in the final stimulus pool. Alcohol‐related pictures (versus neutral pictures) evoked higher arousal, more craving and were judged to have higher alcohol‐relatedness and a more negative valence. Group comparisons indicated that in patients, neutral pictures evoked more craving and had higher alcohol‐relatedness than they did in controls. Physical parameters such as visual complexity, luminance, and color were extracted from these pictures, and extreme values were normalized to minimize mean differences between alcoholic and neutral stimuli. The pictures met the qualitative requirements for (neurophysiological) research. A data file containing rating values and physical parameters will be provided upon request.     

Concordance Rate between Clinical and DIS Diagnoses: A Cross-Cultural Comparison

Abstract: Concordancetes between clinical and DIS-generated diagnoses were compared using data sets from Fukuoka University in Japan and Neuropsychiatry Hospital at the UCLA. An overall concordance rate of 35% between standard clinical diagnosis and DIS-Lifetime diagnosis was discovered in both samples. Next, concordance rates were analyzed by diagnostic category, and differential concordance rates among major diagnostic categories were found in both samples. The highest concordance rates were found in anxiety disorders and major depression. The lowest concordance rates were found in dysthymic disorder and schizophrenia. The Fukuoka sample contained more patients with anxiety disorders and major depression, while the UCLA sample has more patients diagnosed as dysthymic disorder and adjustment disorder. Future directions in cross-cultural psychiatric research are also suggested.     

Parent-child agreement of anxiety symptoms in youth with autism spectrum disorders

Best practice for assessment of anxiety symptoms in children suggests that child self-report is an important element to consider. Yet, it is not known if it is a reliable assessment method for children with high-functioning autism spectrum disorders (ASDs). The present study examines the extent to which verbally fluent children with ASD and their parents agree on the child's symptoms of anxiety. Sixty-three children with ASD and their parents independently completed the Screen for Child Anxiety Related Emotional Disorders (SCARED). Intraclass correlations indicated moderate-to-strong agreement on several domains. Associations among child factors (e.g., verbal IQ, metacognitive ability) and parent-child agreement were explored. More advanced verbal ability was associated with better agreement on Separation, School Avoidance, and Total Anxiety; higher metacognitive skills were associated with better agreement on Social Anxiety. Implications for the use of child self-report are discussed.     

Depression in persons with autism: implications for research and clinical care

Although several studies have investigated the occurrence of medical and neurological conditions in persons with autism, relatively few reports have focused on the phenomenology and treatment of psychiatric disorders in this population. There is emerging evidence that depression is probably the most common psychiatric disorder that occurs in autistic persons. In this review, we examine the factors that influence the presence of depression in this population, such as the level of intelligence, age, gender, associated medical conditions, and the role of genetic factors and life events. We discuss the various forms of treatment available and highlight the need for early detection.     

The associations between substance use disorders, schizophrenia-spectrum disorders, and Axis IV psychosocial problems

Background Substance abuse among individuals with schizophrenia-spectrum disorders (SSDs) is associated with a range of adverse psychosocial outcomes in the areas of occupational functioning, housing stability, economic independence, access to health care, and involvement with the legal system. The aim of this study was to estimate the effects of substance use disorders (SUDs), SSDS, and dual diagnosis with both disorders on the risk for six important Axis IV psychosocial problems. This was accomplished using a large dataset of patients who are representative of individuals in routine US psychiatric practice. Method Weighted data from the 1999 Study of Psychiatric Patients and Treatments from a practice-based research network of the American Psychiatric Institute for Research and Education were analyzed. Some 615 US psychiatrists provided detailed clinical, psychosocial, and health services information on 1,843 patients, including 285 patients with one or more SUDs without an SSD, 180 patients with a diagnosis of an SSD without substance abuse comorbidity, and 68 dually diagnosed patients. Logistic regression models were used to determine effect estimates (adjusted odds ratios), and corresponding 95% confidence intervals were calculated. Results After adjusting for sociodemographic variables and for SSD diagnosis, SUD diagnosis was independently associated with increased risk for five of the Axis IV psychosocial problems of interest (occupational problems, housing problems, economic problems, problems with access to health care services, and problems related to interaction with the legal system/crime) when compared to all other psychiatric patients (n=1,310). After adjusting for the sociodemographic variables and for SUD diagnosis, SSD diagnosis (compared to all other psychiatric diagnoses) was associated with Axis IV economic problems, but not with the other five psychosocial problems of interest. The presence of both an SUD and an SSD diagnosis (dual diagnosis) was associated with a greater risk for four of the six Axis IV psychosocial problems studied, compared to the risks associated with either diagnosis alone. Limiting the substance of abuse to alcohol resulted in similar findings. Conclusions Although SUDs are associated with increased risk for poor social adjustment, the comorbidity of SUDs and SSDs is associated with greatly compounded psychosocial burdens. These findings, from a large sample of representative US psychiatric patients, demonstrate the ongoing need for improved services and policies for those specially burdened patients with the dual diagnosis of both an SSD and substance abuse or dependence.     

Comorbidity of eating disorders with bipolar disorder and treatment implications

OBJECTIVES: To review the scientific evidence examining the comorbidity among eating disorders and bipolar disorder (BD). METHODS: We reviewed all published English-language studies addressing the comorbidity of anorexia nervosa, bulimia, bulimia nervosa, and binge eating disorder in patients with BD and studies of comorbidity of BD in patients with eating disorders. In addition, we discuss the pharmacologic treatment implications from reviewed studies of agents used in BD and eating disorders. RESULTS: Community and clinical population studies of the lifetime prevalence rates of eating disorders in patients with BD, and of BD in patients with eating disorders, particularly when subthreshold and spectrum manifestations of these disorders are included, indicate high rates of comorbidity among these illnesses. CONCLUSIONS: Pharmacologic treatment approaches to patients with BD and a co-occurring eating disorder require examination of the possible adverse effects of the treatment of each syndrome on the other and attempts to manage both syndromes with agents that might be beneficial to both.     

Relation between depression and anxiety in dystonic patients: implications for clinical management

Past clinical research has identified depression as the most common psychiatric disorder associated with cervical dystonia (CD). The purpose of our study is to document different patterns of psychopathology, the frequency of psychiatric disorders, and possible correlation with the neurological disorder in patients with CD. Forty patients with CD were investigated to assess levels of psychopathology on two self-rated scales: the Beck Depression Inventory (BDI) and Symptom Check List (SCL-90). To determine the presence of psychiatric disorders, the patients were evaluated using the standard instrument in the DSM-III-R (Structured Clinical Interview Schedule, SCID). A small group of dystonic patients (12%) had higher levels of psychopathology, with significant amounts of concomitant anxiety and depression on the BDI and SCL-90. SCID criteria for at least one psychiatric disorder were fulfilled in 22 patients (55%), including both the lifetime and current diagnoses. The most frequent diagnostic categories were anxiety (40%) and major depressive disorders (37.5%). In 17 patients (42.5%), criteria for at least one lifetime diagnosis were fulfilled prior to the onset of CD. Psychiatric evaluation does not indicate one specific disorder associated with CD. The presence of anxiety and depression symptoms before and during the course of dystonia, without a possible causal relationship, could mean that the alteration of a chain of physiological events in the central nervous system may not lead to a single clinical picture. The relatively high overall lifetime prevalence of anxiety and depressive disorders may indicate the need for a broader diagnostic and therapeutic approach to patients with focal dystonia.     

DSM-IV mood-, anxiety- and alcohol use disorders and their comorbidity in the Finnish general population

Abstract Background Information on prevalence, accumulation and variation of common mental disorders is essential for both etiological research and development of mental health service systems. Methods A representative sample (6005) of Finlands general adult ( 30 years) population was interviewed in the period 2000–2001 with the CIDI for presence of DSM-IV mental disorders during the last 12 months in the comprehensive, multidisciplinary Health 2000 project. Results Depressive-, alcohol use- and anxiety disorders were found in 6.5%, 4.5 % and 4.1% of the subjects, respectively. A comorbid disorder was present in 19% of those with any disorder. Males had more alcohol use disorders (7.3 % vs. 1.4 %) and females more depressive disorders (8.3 % vs. 4.6 %). Older age, marriage and employment predicted lower prevalence of mental disorders and their comorbidity. Prevalences of alcohol use- and comorbid disorders were higher in the Helsinki metropolitan area, and depressive disorders in northern Finland. Conclusions Mental disorders and their comorbidities are distributed unevenly between sexes and age groups, are particularly associated with marital and employment status, and vary by region. There appears to be no single population subgroup at high risk for all mental disorders, but rather several different subgroups at risk for particular disorders or comorbidity patterns.     

Depressive disorders and alcohol dependence in a community population

This cross-sectional study examines sociodemographic, clinical and functional correlates of comorbid depression in a community sample of 268 individuals with alcohol dependence. Results of analyses comparing drinkers with either current or past depression to never-depressed drinkers showed that respondents in the former two groups were more likely to be female and report more comorbid drug use disorders. In addition to marked functional impairment for currently depressed drinkers, we also found that respondents with past depression were significantly less likely to have health insurance coverage. This lack of insurance for previously depressed persons calls for future work examining the potential influence of this barrier to access care on both clinical and functional outcomes.     

Hierarchical structures of affect and psychopathology and their implications for the classification of emotional disorders

The Diagnostic and Statistical Manual of Mental Disorders-IV groups disorders into diagnostic classes on the basis of the subjective criterion of "shared phenomenological features." The current mood and anxiety disorders reflect the logic of older models emphasizing the existence of discrete emotions and, consequently, are based on a fundamental distinction between depressed mood (central to the mood disorders) and anxious mood (a core feature of the anxiety disorders). This distinction, however, ignores subsequent work that has established the existence of a general negative affect dimension that (a) produces strong correlations between anxious and depressed mood and (b) is largely responsible for the substantial comorbidity between the mood and anxiety disorders. More generally, there are now sufficient data to eliminate the current rational system and replace it with an empirically based taxonomy that reflects the actual-not the assumed-similarities among disorders. The existing structural evidence establishes that the mood and anxiety disorders should be collapsed together into an overarching superclass of emotional disorders, which can be decomposed into three subclasses: the distress disorders (major depression, dysthymic disorder, generalized anxiety disorder, posttraumatic stress disorder), the fear disorders (panic disorder, agoraphobia, social phobia, specific phobia), and the bipolar disorders (bipolar I, bipolar II, cyclothymia). An empirically based system of this type will facilitate differential diagnosis and encourage the ultimate development of an etiologically based taxonomy.     

Prospective analysis of the relation between DSM-III anxiety disorders and alcohol use disorders.

OBJECTIVE: Cross-sectional studies show a robust association between anxiety disorders and alcohol use disorders (comorbidity); however, this methodology does not allow for the testing of causal models. The authors attempted to overcome this limitation by examining comorbid relationships prospectively. METHOD: Male and female college students were assessed as freshmen (year 1), and then again at years 4 and 7, for selected 12-month anxiety disorders (generalized anxiety disorder, agoraphobia, and social phobia or panic) diagnosed according to the National Institute of Mental Health Diagnostic Interview Schedule (DIS) and DSM-III and for 12-month DIS/DSM-III alcohol use disorders (alcohol dependence alone and alcohol abuse or dependence). RESULTS: Cross-sectionally, the odds of having either an anxiety disorder or an alcohol use disorder were two- to fivefold greater when the other condition was present. Prospectively, the odds of developing a new alcohol dependence diagnosis at year 7 increased from 3.5 to five times for those diagnosed with an anxiety disorder at years 1 or 4. Conversely, the odds of developing a new anxiety disorder at year 7 increased by about four times for those diagnosed with alcohol dependence at years 1 or 4. When alcohol abuse and dependence were combined, the pattern of findings was similar, albeit weaker. Multivariate path models provide similar results and highlight the reciprocal influence of alcohol use disorders and anxiety disorders. CONCLUSIONS: Alcohol use disorders (especially alcohol dependence) and anxiety disorders demonstrate a reciprocal causal relationship over time, with anxiety disorders leading to alcohol dependence and vice versa.     

Comorbidity: alcohol use and other psychiatric disorders

Alcohol related disorders often coexist with other psychiatric disorders and its incidence is increasing in last decades. Studies show that patients with comorbidity, specially those with severe psychiatric disorders, have higher rates of suicide, relapse, money spent in treatment, homeless and they use more medical service. Their evaluation must be meticulous because the differential diagnosis become complicated without a long period of alcohol withdrawal. These patients have a worse prognostic and their treatment is more difficult. Most of studies in this area have indicated that the integration of psychosocial and pharmacological techniques is more effective. The long term treatment must focus in the reduction of symptoms, improvement of social and familiar functioning, coping skills and relapse prevention.     

The St George's dementia investigation bed: A study of factors influencing the agreement between clinical and pathological diagnosis

Accurate diagnosis in life of the underlying pathology in the dementias of old age remains difficult despite improvements in the specification of diagnostic criteria. The present study sought to determine the influence of age, comprehensiveness of investigations, severity of dementia and length of delay between investigation and autopsy on the level of clinicopathological diagnostic accuracy achieved. We were unable to identify any single factor which significantly enhanced or impaired overall diagnostic accuracy.