Conflicting measurements of depression in a substance abuse population

Journal of Substance Abuse, 5, 93-100 (1993)

BRIEF REPORT

Conflicting Measurements of Depression in a Substance Abuse Population Horace W. Batson Addiction Research and Treatment Corporation Brooklyn, NY

Lawrence S. Brown, Jr. Addiction Research and Treatment Corporation Brooklyn, NY Harlem Hospital and College of Physicians and Surgeons Columbia University New York, NY

Arturo R. Zaballero Alvin Chu Arthur I. Alterman Center for Studies of Addiction University of Pennsylvania School of Medicine Philadelphia, PA

Methadone maintenance patients (N = 217) were administered a computerized screening version of the National Institute for Mental Health (NIMH) Diagnostic Interview Schedule (DIS), the Beck Depression Inventory (BDI) and the Addiction Severity Index (ASI) 2 - 4 weeks after treatment entry. Few differences were found between African-American, Hispanic, and Caucasian subjects. Only 1.7% of the patients met a lifetime diagnosis of major depressive disorder, and 1.4% qualified for a current diagnosis major depressive disorder. In contrast, 35.8% of the patients reported moderate to serious depression on the BDI during the previous week, and 19.3% reported serious depression during the previous month on the ASI (38.7% lifetime depression). Because moderate correlations were found between the DIS, the BDI, and the ASI measures of depression, there is some indication that they were tapping a similar construct. Therefore the lower rates of depression found with the DIS are probably attributable to its more stringent definition of depression. T h e findings tend to confirm previous literature indicating that the DIS, as contrasted with other structured psychiatric interviews, underestimates depression.

This research was supported by a grant from the National Institute on Drug Abuse (R18-DA060142). Correspondence and requests for reprints should be sent to A r t h u r I. Alterman, Center for Studies of Addiction, University of Pennsylvania School of Medicine, 3900 Chestnut St., Philadelphia, PA 19104-6178. 93

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There is a substantial body of literature indicating that patients entering substance abuse treatment evidence high levels of psychopathology (Hesselbrock, Meyer, & Keener, 1985; Ross, Glaser, & Germanson, 1988; Rounsaville, Kosten, Weissman, & Kleber, 1982; Schuckit, 1985). It has been further observed in a number of studies that substance abuse patients who evidence psychopathology respond poorly to treatment (Hasin, Grant & Endicott, 1988; Pottenger et al., 1978; Rounsaville, Dolinsky, Babor, & Meyer, 1987; Schuckit, 1985). For example, McLellan and his colleagues (McLellan, Luborsky, Woody, O'Brien, & Druley, 1983) have shown that substance abusers with elevated psychiatric severity scores on the Addiction Severity Index (ASI) appear to benefit less from treatment. Other studies have shown that abusers who qualify for an Antisocial Personality Diagnosis (APD) do not do as well in treatment as non-APDs (Penick et al., 1984; Rounsaville et al., 1987; Woody, McLellan, Luborsky, & O'Brien, 1985). Additionally, research has shown (particularly in men) that those with major depression respond less favorably to treatment than those with no additional disorders (Rounsaville et al., 1987). Therefore, the accurate assessment of depression and other psychiatric disorders is important to any effort to match treatment to the patient's needs. In general, high rates of depression have been found in substance abusers. High rates of a diagnosis of major depression have been found in substance abusers when the Schedule for Affective Disorders and Schizophrenia-Lifetime (SADS-L), a structured psychiatric interview, has been used (Hasin & Grant, 1987; Hasin et al., 1988; Hesselbrock, Stabenau, Hesselbrock, Mirkin, & Meyer, 1982). For example, Hasin and Grant (1987) found a 67% lifetime rate of major depression using the SADS. Similarly, studies using depression scales such as the Beck Depression Inventory (BDI) or the Hamilton Depression Rating Scale (HDRS) with substance abusers have reported moderate to severe symptom levels in approximately one-third to two-thirds of opiate-dependent persons (P.R. Robins, 1974; Rounsaville, Rosenberger, Wilber, Weissman, & Kleber, 1980; Steer & Kotzker, 1980; Wieland & Sola, 1970). Research utilizing the Minnesota Multiphasic Personality Inventory also has shown high levels of depression among newly admitted substance abusers (Gilbert & Lombardi, 1967; Olson, 1964; Sutker, 1971). It is surprising, therefore, that Hasin and Grant (1987) found relatively low rates of depression (19% with probable diagnosis included) in substance abusers when the Diagnostic Interview Schedule (DIS), another structured psychiatric interview, was employed. Similarly low levels of major depression have been obtained when the DIS was administered to a general population, that is, 6% current primary unipolar depression (Oliver & Simmons, 1985). Interestingly, for those same patients, higher rates of depression (19.8%) were found with the BDI. Hesselbrock et al.'s (1985) finding with the DIS of a 32% rate of lifetime major depression in hospitalized alcoholic men and a 52% rate in alcoholic women represents somewhat of an exception; but these rates are still relatively low compared with those obtained for the SADS. The studies that we have described either involved predominantly white alcoholic patients or failed to provide ethnic/racial breakdowns of the data. It would

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be important to know whether substance abusers of different racial/ethnic backgrounds differ in depression, inasmuch as there is currently little systematic data concerning the characteristics of minority substance abusers (Brown & Alterman, 1992). In conjunction with an ongoing treatment outcome study of primarily African-American and Hispanic methadone maintenance .patients, we have included several measures of depression: the DIS, the BDI and the ASI. This allowed us to examine depression in African-American, Hispanic, and Caucasian research participants from the differing perspectives provided by these three instruments. METHODS Subjects

Subjects were recruited from May through September 1991. Of all the patients approached during this time, 50% agreed to participate. The study sample consisted of 124 (57.1%) opiate-dependent men and 93 (42.9%) women, all new patients (i.e., enrolled in treatment for at least 2 weeks and not more than 1 month) admitted into the Addiction Research and Treatment Corporation (ARTC), a community-based treatment and research facility with six methadone maintenance clinics in New York City. There were 109 (50.2%) African-Americans, 92 (42.4%) Hispanics, and 16 (7.4%) white subjects. The mean age of the patients was 36.4 years (SE = .50), and 12.6% were married. The average number of years of education was 11.0 (SE = .15). Procedures

All subjects were provided with complete information about the study prior to obtaining informed consent. They were paid a total fee of $20.00 for completing the DIS, the BDI, and the ASI, which were administered on an individual basis by a research technician. The evaluations took approximately 1 to 3 hours to complete. They were usually distributed over two sessions/days and were not administered in any fixed order. Administration order was based on subject availability. The instruments employed in the study are described in more detail next. Diagnostic Interview Schedule The DIS is a highly structured interview, which, when used in conjunction with the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria (American Psychiatric Association, 1980), yields information on the psychiatric diagnoses for which the patient qualifies. There is considerable evidence supporting the reliability and validity of this instrument (Helzer et al., 1985; L.N. Robins, Helzer, Croughan, & Ratcliff, 1981). Three of the seven study research technicians were trained at Washington University in St. Louis, where the DIS was developed. Interrater agreement for DIS ratings of the seven technicians was determined by scoring interviews (in person) of 10 opiate-dependent pilot subjects. Reliabilities for the various diagnoses ranged from 0.75 to 0.97.

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A computerized screening version o f the DIS (Greist et al., 1987) was used instead o f the standard manual version, to expedite administration. This instrument is modeled after the DIS, but saves time by skipping out of a diagnostic section once a respondent meets criteria for that diagnosis. As a result, the number of symptoms, time of onset, and recency data for all symptoms cannot be determined for those who qualify for a diagnosis. Beck Depression Inventory

This is a self-report, 21-item questionnaire measuring depression. Each item consists of groups of descriptive statements depicting varying levels of sad or blue'themes and/or feelings that the patient is asked to rate (from 0 to 3), indicating agreement. The patient is asked to select the descriptive sad statement, feeling, or theme that best describes the way that he or she has been feeling over the "past week, including the day that the form is completed. T h e total depression score consists of the sum of the individual items. A score of 0 - 9 indicates no depression; 10-15, mild depression; 16-23 moderate depression; and 24-63 serious depression (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Addiction Severity Index

The ASI (McLellan, Luborsky, Woody, & O'Brien, 1980) is a 45-minute, semistructured, technician-administered interview that obtains relevant sociodemographic and problem-level information in seven areas of life functioning: medical, legal, employment, family/social, psychological/emotional, drug, and alcohol. Considerable data are available supporting the reliability and validity of this instrument (McLellan et al., 1980, 1985). In this study we focused on the ASI items dealing with depression experienced in the past 30 days and during the respondent's life. T h e six research technicians were trained on the ASI by trainers from the University of Pennsylvania, where the instrument was developed. Interrater reliabilities ranged from 0.78 to 1.00 for the ASI composite scores for the seven areas of life functioning. RESULTS Rates o f Depression for the Different Measures

Table 1 shows the proportion of subjects qualifying for lifetime and current (past 30 days) diagnoses of major depression, using the DIS. Also shown are the proportion of subjects qualifying for probable diagnoses of depression. In general, a probable diagnosis is given if a respondent is within one symptom of getting a positive diagnosis. Also, if the respondent reports enough symptoms, but the duration was short of the criterion for a diagnosis, this would constitute a probable classification. Table 1 also describes the proportion of subjects reporting moderate and severe levels of depression during the past week on the BDI and reporting

Conflicting Measurements of Depression

Table 1.

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Rates of Depression (N = 217) Measures

%

DIS-life-definite DIS-life-probable DIS-current-definite DIS-current-probable Beck-moderate/severedepression ASI-life-seriousdepression ADI-30 days-seriousdepression

1.7 10.9 1.4 9.1 35.8 38.7 19.3

serious depression on the ASI during the past month and in the respondent's lifetime. As can be seen, based on the DIS, only 1.7% of our sample qualified for a lifetime diagnosis of major depression, whereas 1.4% met criteria for this diagnosis within the past month. An additional 10.9% and 9.1% of the subjects met criteria for a probable, lifetime, or current DIS diagnosis, respectively. Therefore, the DIS identified remarkably few definite, or clearcut, diagnoses of major depression. In contrast, 35.8% of our subjects reported moderate to severe symptoms of depression during the past week on the BDI. Similarly, 38.7% of the subjects reported experiencing serious lifetime depression on the ASI, and 19.3% reported serious depression in the past 30 days. It is noteworthy that few racial/ethnic differences were revealed in reported depression; the only exception to this finding being that both the African-American (46.3%) and the Caucasian (43.8%) subjects were significantly (p < .05) more likely to report serious lifetime depression on the ASI than the Hispanic subjects (29.0%). Intercorrelations Between Various Measures of Depression

Because of the differences that were obtained among the findings for the different measures, it was important to determine whether the measures were assessing different concepts or whether they differed primarily in sensitivity. In an effort to answer this question, the degree of association among the instruments was examined (see Table 2). In general, the various instruments showed small to moderate intercorrelations. The BDI was more highly correlated with the DIS when probable diagnoses were included. These findings provide supTable 2.

Correlations Between Different Measures of Depression DIS-L

Def. + Prob. DIS-life-definite DIS-life-def. + probable DIS-current-definite DIS-current-def. + prob. ASI-lifetime ASI-past 30 days

0.41

DIS-current Def.

0.89 0.36

ASI

DIS-current

Def. + Prob.

ASI-L

30 Days

BDI

0.44 0.72 0.50

0.07 0.13 0.10 0.08

0.24 0.17 0.20 0.15 0.46

0.07 0.22 0.02 0.27 0.11 0.17

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port for a "threshold" or sensitivity interpretation of the results. This trend was less apparent for the relationships between the DIS and the ASI measures. DISCUSSION

Remarkably few of our methadone-maintained research subjects qualified for a diagnosis of major depression on the DIS. This finding is to be contrasted with considerably higher rates of depression reported by the same subjects on the BDI and the ASI. Because our analyses revealed significant relationships among the different measures of depression, it appears that the differences between them in the absolute levels of serious depression may be largely due to differences in their sensitivity. There could be several reasons for the low rates of major depression found with the DIS. Of relevance are the findings of a study by Hasin and Grant (1987). These investigators administered both the DIS and the SADS to the same subjects and found that the SADS diagnosed major depressive disorder (MDD) four times as often as the DIS. Practically all discrepancies between the two instruments occurred because the SADS diagnosed MDD when the DIS did not. They concluded that the DIS requirement that depression be independent of drug use was largely responsible for this outcome. It is likely, therefore, that similar factors were active in the current study. Unfortunately, the computerized version of the DIS employed in the study did not allow us to evaluate the drug attribution aspect of the DIS. Thus, major depression rates without the attribution could not be determined. Another possible explanation for the low rates of MDD yielded by the DIS is that this study used a computer version of the DIS (Greist et al., 1987) based on DSM-III criteria. Since then, a computer screening version of the DIS based on the DSM-III-R criteria has become available. However, the DSM-III-R criteria for MDD are similar to those of the DSM-III. Diagnostic criteria are, of course, more restrictive with the designation of depression, and this may explain the differences to some extent between the DIS and the two other instruments in this study. However, because major depression rates of 67% have been found with the SADS, this only partially explains the low rates of MDD found with the DIS in this study. It is possible that the low rates of MDD were attributable to the high representation of African-Americans and Hispanics in the study. But this is unlikely, given the fact that the rates of depression of the three racial/ethnic groups did not differ and high proportions of racial/ethnic minorities have been included in previous studies (although the data for these groups has not been reported separately). One serious limitation of the present study is that we recruited just 50% of the prospective subjects into the study. Therefore, the findings may not be representative of our entire potential patient population. It is possible that patients who declined to participate were more depressed and we would have seen an increase in the degree of reported depression if they had been included. However, we have no reason to believe that these increases would have been different for the three measures studied, and it is not likely that major increases in diagnosed depression would have been found.

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O n t h e basis o f t h e s t u d y f i n d i n g s , it w o u l d a p p e a r t h a t t h e D I S u n d e r e s t i m a t e s s e r i o u s d e p r e s s i o n . I n c l u d i n g p r o b a b l e d i a g n o s e s , as well as d e f i n i t e d i a g n o s e s , m a y p a r t i a l l y c o r r e c t f o r this s i t u a t i o n . N o n e t h e l e s s , i n s t r u m e n t s s u c h as t h e B D I w o u l d s e e m to b e m o r e a p p r o p r i a t e s c r e e n i n g tools f o r s e r i o u s d e p r e s s i o n in s u b s t a n c e a b u s e p a t i e n t s . A l s o , w h e n t h e D I S is e m p l o y e d , it m a y b e h e l p f u l to a d m i n i s t e r t h e d e p r e s s i o n s e c t i o n b o t h w i t h a n d w i t h o u t t h e d r u g a t t r i b u t i o n p r o c e d u r e , as t h e l a t t e r a p p r o a c h a p p e a r s to p r o d u c e r e s u l t s t h a t a r e more consistent with the literature. REFERENCES

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. Beck, A.T., Ward, C.H., Mendelson, M., Mock, J.E., & Erbaugh, J.K. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Brown, L., & Alterman, A. (1992). Problems of substance abuse in African-Americans. In J.H. Lowinson, P. Ruiz, & R.B. Millman (Eds.), Comprehensivetextbook of substance abuse (pp. 861867). Baltimore: Williams & Wilkins. Gilbert, J.G., & Lombardi, D.N. (1967). Personality characteristics of young male narcotic addicts. Journal of Consulting Psychology, 31,536-538. Greist, J.H., Klein, M.H., Erdman, H.P., Bires, J.K., Bass, S.M., Machtinger, EE., & Kresge, D.G. (1987). Comparison of computer and interviewer-administered versions of the Diagnostic Interview Schedule. Hospital and Community Psychiat~, 38, 1304-1311. Hasin, D.S., & Grant, B.F. (1987). Diagnosing depressive disorders in patients with alcohol and drug problems: A comparison of the SADS-L and the DIS.Journal of Psychiatric Research, 21,301311. Hasin, D.S., Grant, B.F., & Endicott, J. (1988). Lifetime psychiatric comorbidity in hospitalized alcoholics: Subject and familial correlates. InternationalJournal of the Addictions, 23, 827-850. Helzer, J.E., McEvoy, L.T., Robins, L.N., Spitznagel, E., Stoltsman, R.K., Farmer, A., & Brockington, I.F. (1985). Results of the St. Louis ECA physician re-examination study of the DIS interview. Archives of General Psychiatry, 42, 657-666. Hesselbrock, M.N., Meyer, R.E., & Keener, J.J. (1985). Psychopathology in hospitalized alcoholics. Archives of General Psychiatry, 42, 1050-1055. Hesselbrock, V., Stabenau, J., Hesselbrock, M., Mirkin, P., & Meyer, R.A. (1982). A comparison of two interview schedules: The Schedule for Affective Disorders and Schizophrenia-Lifetime and the National Institute for Mental Health Diagnostic Interview Schedule. Archives of General Psychiatry, 239, 674-677. McLellan, A.T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., Barr, H.L., & O'Brien, C.P. (1985). New data from the Addiction Severity Index: Reliability and validity in three centers.Journal of Nervous Mental Disease, 173, 412-423. McLellan, A.T., Luborsky, L., Woody, G.E., & O'Brien, C.P. (1980). An improved evaluation instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous Mental Disease, 168, 26-33. McLellan, A.T., Luborsky, L., Woody, G.E., O'Brien, C.P., & Druley, K. (1983). Predicting response to alcohol and drug abuse treatments: Role of psychiatric severity. Archives of General Psychiatry, 40, 620-625. Oliver, J.M., & Simmons, M.E. (1984). Depression as measured by the DSM-III and the Beck Depression Inventory in an unselected adult population.Journal of Consulting and Clinical Psychology, 52, 892-898. Olson, R.W. (1964). MMPI sex differences in narcotic addicts.Journal of Genetic Psychology, 71,257266. Penick, E., Powell, J., Othmer, E., Bingham, S.F., Rice, A.S., & Liese, B.S. (1984). Subtyping alcoholics by co-existing psychiatric syndromes: Course, family history, outcome. In D.W. Goodwin, R.T.

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Van Dusen, & S.A. Mednick (Eds.), Longitudinal researchin alcoholism. Hingham, MA: KluwerNijhoff. Pottenger, M., McKernon,J., Patrie, L.E., Weissman, M.M., Ruben, H.L., & Newberry, P. (1978). The frequency and persistence of depressive symptoms in the alcohol abuser. Journal of Nervous Mental Disease, 166, 562-570. Robins, L.N., Helzer, J.E., Croughan, J., & Ratcliff, K.S. (1981). The NIMH Diagnostic Interview Schedule: Its history, characteristics and validity. Archives of General Psychiatry, 38, 381-389. Robins, P.R. (1974). Depression and drug addiction. Psychoanalytic Quarterly, 48, 375-386. Ross, H.E., Glaser, EB., & Germanson, T. (1988). The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Archives of General Psychiatry, 45, 1023-1031. Rounsaville, B.J., Dolinsky, Z.S., Babor, T.F., & Meyer, R.E. (1987). Psychopathology as a predictor of treatment outcome in alcoholics. Archives of General Psychiatry, 44, 505-513. Rounsaville, B.J., Kosten, T.R., Weissman, M.M., & Kleber, H.D. (1982). Prognostic significance of psychiatric disorders in treated opiate addicts. Archives of General Psychiatry, 39, 151-156. Rounsaville, B.J., Rosenberger, P., Wilber, C.V., Weissman, M.M., & Kleber, H.D. (1980). A comparison of the SADS/RDC and the DSM-III: Diagnosing drug abusers. Journal of Nervous Mental Disease, 168, 90-97. Schuckit, M.A. (1985). Studies of populations at high risk for alcoholism. PsychiatricDevelopments,3, 31-63. Steer, R.A., & Kotzker, E. (1980). Affective changes in male and female methadone patients. Drug and Alcohol Dependence, 5, 115-122. Sutker, P.B. (1971). Personality differences and sociopathy in heroin addicts and nonaddict prisoners. Journal of Abnormal Psychology, 78, 247-251. Wieland, W.E, & Sola, S. (1970). Depression in opiate addicts as measured by objective tests. In Proceedings of the Third National Conference on Methadone Treatment (pp. 75-79), New York: National Association for the Prevention of Addiction to Narcotics. Woody, G.E., McLellan, A.T., Luborsky, L., & O'Brien, C.P. (1985). Sociopathy and Psychotherapy Outcome. Archives of General Psychiatry, 42, 1081-1086. i