Psychiatric comorbidities in opioid-dependent patients undergoing a replacement therapy programme in Spain: The PROTEUS study
Introduction
Clinical and epidemiological studies have revealed a high and broad rate of comorbid psychiatric disorders (44–93%) in opioid-dependent (OD) patients (Mateu et al., 2005), including those with prescription opioid dependence (Gros et al., 2013, Pereiro et al., 2013). In a Spanish sample of OD patients in a methadone maintenance programme (Astals et al., 2009), 32.3% had co-occurring mental disorders or a dual diagnosis (over half of them with Axis I disorders alone), and the prevalence seems to be increasing with time (Sanvisens et al., 2014).
The different diagnostic criteria used in the studies are probably the major contributor to the large variability in the reported prevalence (Mateu et al., 2005, Nunes and Rounsaville, 2006, Schuckit, 2006). However, a high prevalence of psychiatric comorbidities, especially depressive, anxiety, and personality disorders, in OD population, is well established (Haro et al., 2004, Roncero et al., 2012; Strain, 2002; Wu et al., 2013). The presence of previous mental disorders has been shown to be a predictor of incident substance use/dependence (Katz et al., 2013, Maremmani et al., 2011a, Reidy et al., 2014). However, substance use may also be cause of inducing psychiatric disorders, such as stimulant- or drug-induced psychoses and substance-induced mood disorders, as well as substance-induced anxiety conditions (Maremmani et al., 2011a, Schuckit, 2006).
Overall, OD patients seeking treatment show a poor quality of life (QoL) (Astals et al., 2008), which seems to be worse in those with a dual diagnosis (Bizzarri et al., 2005, Fassino et al., 2004, Iskandar et al., 2013). Thus, the need to treat concomitant mental disorders must be emphasized in patients receiving OD treatment. The importance of assessing psychiatric comorbidities in these patients has further implications because these comorbidities seem to have a certain influence on costs (Roncero et al., 2015) as well as on treatment outcomes and patients QoL. In fact, some psychiatric symptoms in OD patients are associated with drug misuse and thus show rapid remission after drug-dependence treatment (Gossop et al., 2006). Furthermore, it seems that patients with dual diagnosis on methadone treatment show better outcomes than OD patients with no psychiatric comorbidities (Maremmani et al., 2013, Ngo et al., 2011), although the additional medication for the treatment of psychiatric symptoms might partly explain these more positive outcomes (Maremmani et al., 2013). In addition, opiate treatment can have a different outcome not only in patients with or without dual diagnosis but also, depending on the specific type of treatment, a more or less pronounced effect in different groups (Schafer et al., 2010).
The available studies in Spain regarding patients with dual diagnosis are scarce, and thus more studies should be conducted to characterize this group of patients. With this aim in mind, we proceeded to assess the psychiatric comorbidities of a large OD population enrolled in opioid agonist treatment (OAT) programmes in Spanish care centres and to compare the different sociodemographic (including gender) and clinical characteristics (including severity and type of treatment used) according to the presence of at least one comorbid psychiatric disorder (i.e., whether patients had or did not have dual pathology), with specially focus on mood, anxiety and sleep disorders due to their high frequency among patients with dual pathology and on psychotic disorders due to their severity.
Section snippets
Patients and variables
The methods are described in detail in (Roncero et al., 2011). The PROTEUS study was an observational, cross-sectional, descriptive, multicentre, epidemiological study conducted in healthcare centres for patients with OD. The study was approved by the Clinical Research Ethics Committee of the Vall d’Hebron University Hospital (Barcelona, Spain), and it was conducted according to the Declaration of Helsinki (Tokyo, 2004).
Patients who were at least 18 years old, diagnosed with OD according to the
Overall patient characteristics
A total of 624 patients from 74 centres were enrolled, and 621 were analysed because 3 did not meet the study inclusion criteria (Roncero et al., 2011).
The sociodemographic and clinical characteristics of the study population have been previously described (Roncero et al., 2011, Roncero et al., 2013). Overall, the mean age was 38.9 years, 84% were men, 47% were unemployed, 19% had legal problems, and 52% drove regularly. Most (94%) were being treated with methadone, 59% had infectious
Discussion
Previous studies have revealed a high rate of psychiatric comorbidities in OD patients (Mateu et al., 2005, Pereiro et al., 2013, Schuckit, 2006, Strain, 2002) and a higher risk of experiencing these psychiatric disorders compared to the general population (Fan et al., 2014). However, there were few available data regarding this issue in Spain, and thus we aimed to determine the prevalence of dual diagnosis among OD patients in OAT programmes; our analyses showed a high rate of dual diagnosis
Conflict of interest
Carlos Roncero has received fees to give talks for Janssen-Cilag, Bristol-Myers Squibb, Ferrer-Brainfarma, Pfizer, Reckitt-Benckiser/Indivior, Lundbeck, Otsuka, Servier, Lilly, Shire, GSK, Rovi and Astrazeneca. He has received financial compensation for his participation as a member of the Janssen-Cilag, Lilly, and Gilead. Carmen Barral has received fees to give talks for Otsuka. Laia Rodríguez-Cintas has no conflicts of interest. Jesús Pérez-Pazos has received fees to give talks for Janssen.
Role of the funding source
The PROTEUS project was supported by an unrestricted Reckitt-Benckiser/Indivior Grant, which also financed the medical writing services. The funding source had no involvement in the study design, in the collection, analysis and interpretation of data or in the decision to submit the article for publication.
Acknowledgements
We would like to thank Almudena Pardo Mateos, Ph.D., for writing the first draft of the manuscript and assisting with its editing and Inmaculada Fierro for management of the database. Reckitt-Benckiser/Indivior provided the grant funding for the PROTEUS project.
References (78)
- et al.
The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients
Drug Alcohol Depend.
(2001) - et al.
History of sexual, emotional or physical abuse and psychiatric comorbidity in substance-dependent patients
Psychiatry Res.
(2015) - et al.
Psychotic disorders among inpatients with abuse of cannabis, amphetamine and opiates. Do dopaminergic stimulants facilitate psychiatric illness?
Eur. Psychiatry
(1999) - et al.
Patterns and correlates of attempted suicide amongst heroin users: 11-year follow-up of the Australian treatment outcome study cohort
Psychiatry Res.
(2015) - et al.
Psychiatric disorders associated with high-dose methadone (>100 mg/d): a retrospective analysis of treated patients
Therapie
(2012) - et al.
Quality of life and personality disorders in heroin abusers
Drug Alcohol Depend.
(2004) - et al.
Are opioid-dependent/tolerant patients impaired in driving-related skills? a structured evidence-based review
J. Pain. Symptom Manag.
(2003) - et al.
Gender and comorbidity among individuals with opioid use disorders in the NESARC study
Addict. Behav.
(2009) - et al.
The role of personality disorders on drug dependence treatment outcomes following inpatient detoxification
Eur. Psychiatry
(2004) - et al.
Sleep disturbances and pain among individuals with prescription opioid dependence
Addict. Behav.
(2014)
Incidence of psychopathology in a cohort of young heroin and/or cocaine users
J. Subst. Abus. Treat.
Risk factors for incident nonmedical prescription opioid use and abuse and dependence: results from a longitudinal nationally representative sample
Drug Alcohol Depend.
Higher methadone doses are associated with lower mortality in patients of opioid dependence in Taiwan
J. Psychiatr. Res.
Factors affecting cognitive function of opiate-dependent patients
Drug Alcohol Depend.
The long-term outcomes of heroin dependent-treatment-resistant patients with bipolar 1 comorbidity after admission to enhanced methadone maintenance
J. Affect Disord.
Variables associated with perceived sleep disorders in methadone maintenance treatment (MMT) patients
Drug Alcohol Depend.
Depression in methadone maintenance treatment patients: rate and risk factors
J. Affect Disord.
Pain depression and sleep disorders among methadone maintenance treatment patients
Addict. Behav.
Underestimation of substance abuse in psychiatric patients by conventional hospital screening
J. Psychiatr. Res.
Psychiatric comorbidity in young heroin users
Drug Alcohol Depend.
Characteristics of heroin dependent patients admitted to a methadone treatment program
Med. Clin.
Prevalence of mood and substance use disorders among patients seeking primary care office-based buprenorphine/naloxone treatment
Drug Alcohol Depend.
Obstructive sleep apnea is more common than central sleep apnea in methadone maintenance patients with subjective sleep complaints
Drug Alcohol Depend.
Assessing sleep in opioid dependence: a comparison of subjective ratings, sleep diaries, and home polysomnography in methadone maintenance patients
Drug Alcohol Depend.
The impact of probable anxiety and mood disorder on self-reported collisions: a population study
J. Affect Disord.
Comorbid substance use disorders with other Axis I and II mental disorders among treatment-seeking Asian Americans, Native Hawaiians/Pacific Islanders, and mixed-race people
J. Psychiatr. Res.
Madrid study on the prevalence and characteristics of outpatients with dual pathology in community mental health and substance misuse services
Adicciones
Impact of substance dependence and dual diagnosis on the quality of life of heroin users seeking treatment
Subst. Use Misuse
Impact of co-occurring psychiatric disorders on retention in a methadone maintenance program: an 18-month follow-up study
Int. J. Environ. Res. Public Health
Influence of peak and trough levels of opioid maintenance therapy on driving aptitude
Eur. Addict. Res.
Pain and motives for use among non-treatment seeking individuals with prescription opioid dependence
Am. J. Addict.
Dual diagnosis and quality of life in patients in treatment for opioid dependence
Subst. Use Misuse
Impacts of shift work on sleep and circadian rhythms
Pathol. Biol.
Managing psychiatric comorbidity within versus outside of methadone treatment settings: a randomized and controlled evaluation
Addiction
Psychiatric comorbidity reduces quality of life in chronic methadone maintained patients
Am. J. Addict.
Influence of attention deficit hyperactivity disorder and conduct disorder on opioid dependence severity and psychiatric comorbidity in chronic methadone-maintained patients
Eur. Addict. Res.
The role of psychiatric disorders in predicting drug dependence treatment outcomes
Am. J. Psychiatry
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