Elsevier

Psychiatry Research

Volume 243, 30 September 2016, Pages 174-181
Psychiatry Research

Psychiatric comorbidities in opioid-dependent patients undergoing a replacement therapy programme in Spain: The PROTEUS study

https://doi.org/10.1016/j.psychres.2016.06.024Get rights and content

Highlights

  • In total, 621 OD patients in Spanish OAT programmes were assessed for psychiatric comorbidities.

  • Psychiatric comorbidities were detected in 67% of patients.

  • Dual patients showed more infectious and non-infectious comorbidities than non-dual patients.

  • Dual patients showed worse working status and a higher severity of problems.

  • Dual patients were older and used benzodiazepines and cannabis more frequently.

Abstract

Opioid-dependent patients show a high rate of psychiatric comorbidities. The prevalence and characteristics of patients with dual diagnosis have not been well established in Spanish opioid agonist treatment (OAT) programmes. Thus, 621 opioid-dependent patients enrolled in OAT programmes were assessed, using the EuropASI questionnaire, for psychiatric comorbidities, which were detected in 67% of patients (anxiety 53%, mood disorders 48%, sleep disorders 41%, substance-related disorders 36%). In addition, compared with patients without a dual diagnosis, patients with dual pathology were significantly older, used benzodiazepines and cannabis in significantly greater percentages, and showed significantly more frequent infectious and non-infectious comorbidities, worse overall working status, a lower proportion of drivers and higher levels of severity regarding medical, employment, alcohol, legal, family and psychological issues. Therefore, the data showed a very high prevalence of psychiatric comorbidity in opioid-dependent patients receiving OAT in Spain and several problems frequently associated with patients with dual diagnosis. Physicians treating opioid-dependent patients should be aware of these facts to correctly identify and manage patients with a dual diagnosis.

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.

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