Adverse impact of marijuana use on clinical outcomes among psychiatry patients with depression and alcohol use disorder
Introduction
Prior research examining the comorbidity of psychiatric conditions and substance use disorders (SUDs) suggests that alcohol use disorders (AUDs) are significantly comorbid with depression (Grant et al., 2004, Schuckit, 2009, Conner et al., 2009, Pacek et al., 2013). In the United States, 7% (about 16 million) of adults aged 18 or older had major depressive episodes in 2014–2015, and the prevalence of AUDs (DSM-IV abuse or dependence) among adults with major depressive episodes was 14%, twice as prevalent with depression as any other SUD (Substance Abuse and Mental Health Services Administration, 2014). Given the substantial comorbidity of depression and AUD, the characteristics and subsequent outcomes of persons with these disorders have become high priorities for prevention and treatment research.
The significant comorbidity of depression and AUD found in the general population is more striking in clinical populations. Specifically, studies conducted with either psychiatry or addiction treatment seeking samples have found 50–70% of patients with depression had AUDs (Sullivan et al., 2005, Conner et al., 2009). In addition, patients with depression and AUDs who present for psychiatry treatment have higher rates of drug use, more severe depressive symptoms, and functional impairment than patients with depression but without AUDs (Conner et al., 2009, Sher et al., 2008). A general population-based study found that individuals with co-occurring alcohol and marijuana use disorders were more likely to have major depressive episodes relative to those with either alcohol or marijuana use disorder alone (Pacek et al., 2012). Longitudinal studies indicate that patients with both depression and AUDs continue to demonstrate greater depressive symptoms and functional impairment over time than patients with depression alone (Conner et al., 2009). Less is known, however, about the extent of drug use over time, and whether it has differential effects on clinical outcomes for those with depression and AUDs. Although a review by Conner et al. (2009) concluded that drug use was associated with greater depression severity and functional impairment in treatment seeking patients with depression and AUD, this review is almost 10 years old and was limited to cross-sectional studies. To our knowledge, there has been no recent longitudinal examination of symptom and functional outcomes in terms of marijuana use among psychiatry outpatients with depression and AUD.
Marijuana is the most commonly used drug in the U.S. (SAMHSA, 2014), with 8.3% of adults reporting past month use. General population-based research among individuals with depression has found no association between marijuana use and depression pathology over time (Feingold et al., 2017). Yet, research in clinical samples has shown that marijuana use is associated with worse overall psychopathology and poorer functioning among psychiatry patients with depression, and that these adverse clinical outcomes persist over time (Bahorik et al., 2013). Psychiatry patients with comorbid depression and AUD (Conner et al., 2009, Sullivan et al., 2005) may have additional problems related to marijuana use, owning to its association with poor clinical outcomes among clinical samples (Bahorik et al., 2017, Bahorik et al., 2013, Trull et al., 2016). A study focused on marijuana use in psychiatry patients with depression and AUD may characterize an important subgroup at risk of poor clinical outcomes and contribute information to future prevention and intervention strategies.
We explored whether marijuana use was associated with clinically problematic outcomes for patients with depression and AUD by analyzing 6 month follow up data in a secondary analysis of 307 individuals who participated in a randomized trial for substance use treatment, delivered in a psychiatry outpatient setting. This larger question was addressed through carrying out three study aims. First, we examined whether differences in marijuana use existed at baseline between patients with and without AUD. Second, we examined whether differences in marijuana use existed over 6 months between patients with and without AUD. Finally, we investigated whether differences existed between patients with and without AUD in terms of marijuana use, depressive symptom and functional outcomes over the follow-up. Building on our prior work showing that marijuana use has adverse effects on depression (Bahorik et al., 2017), findings will provide important information about the differential impact of marijuana use on those with comorbid depression and AUD, and inform drug use prevention and intervention efforts.
Section snippets
Participants and procedures
Data for this secondary analysis were drawn from individuals who had participated in a randomized controlled trial of motivational interviewing (MI) for substance use treatment for patients with depression, delivered in an outpatient psychiatry setting. Patients were recruited from Kaiser Permanente Southern Almeda Medical Center Department of Psychiatry in Union City and Fremont, California. These psychiatry clinics provide evaluation, psychotherapy, and medication management for patients with
Participant characteristics at baseline
As shown in Table 1, the sample was 70.3% women, 38.1% white, 21.1% Hispanic, 14.0% Asian, 21.8% black, and 4.2% other race/ethnicity. Participants were 37 years old on average (SD = 13.10), and 53.0% had a household income ≥ $50 K. Fifty-six percent of the sample had PHQ-9 scores (score ≥ 10) that suggested the presence of DSM-IV major depressive disorder. Most patients were employed (64.6%), and less than half were married (42.0%). A considerable number of participants had AUD, with 149
Discussion
Drug use is often comorbid with both depression and AUD, and may negatively affect the outcomes of patients receiving psychiatric services. We conducted secondary analyses of 307 patients with depression and AUD from a trial of substance use treatment for depression, and examined marijuana use, depressive symptoms, and functional outcomes over 6 months.
Consistent with prior research on alcohol and drug use among psychiatry patients with depression (Sullivan et al., 2005, Conner et al., 2009,
Acknowledgements
We thank Georgina Berrios for assistance in conducting the study.
Conflict of interest
None.
Role of funding source
This study was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA: R01 AA020463) and the National Institute on Drug Abuse (NIDA: T32DA007250). The funding sources provided no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
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