Risk factors for substance use disorders among inpatients with major affective disorders in Taiwan Chinese

Risk Factors for Substance Use Disorders Among Inpatients with Major Affective Disorders in Taiwan Chinese Ya-Mei Bai, M.D., Chao-Cheng Lin, M.D., Pei-Gi Hu, M.D., and Hong-Shiow Yeh, M.D. Abstract: An assessment of potential risk factors for substance use disorders was performed in 49 patients with major affective disorders in a general hospital acute care unit in Taiwan. The major depression patients were noted to have a higher prevalence of substance use disorder than bipolar disorder patients (p 5 0.011). Those patients with substance use disorders were noted to be significantly male-predominated (p 5 0.043), to have a later onset age of affective disorder (p 5 0.009), and to have more visits to the emergency room in the recent one year (p 5 0.009). The sedatives-hypnotics-anxiolytics was the most frequently used forms of drug abuse. The major depression patients had a significantly higher sedative-hypnoticsanxiolytics use disorder rate than the bipolar disorder patients (p 5 0.001). All patients with alcohol use disorder were noted to have other substance use disorders as well. Fifty six percent of those patients with substance use disorder were polysubstance users. Eighty three percent of the male patients with substance use disorder had poly-substance use disorder. © 1998 Elsevier Science Inc.

Introduction The significant prevalence of substance use disorders among psychiatric patients has attracted increasing interest. The prevalence of substance abuse among psychiatric patients is higher than that of the general population [1]. The outcome for psychiatric patients with substance use disorders is reported to Department of Psychiatry, Yu-Li Veterans Hospital, Hua-Lien, Taiwan (Ya-Mei Bai and Chao-Cheng Lin), Department of Family Medicine, The 807 Military General Hospital, Taipei, Taiwan (Pei-Gi Hu), Department of Psychiatry, Veterans General Hospital-Taipei, Taipei, Taiwan (Hong-Shiow Yeh) Address reprint requests to: Ya-Mei Bai, M.D., Department of Psychiatry, Yu-li Veterans Hospital, 91, Hsin Hsing St., Hua-Lien, Taiwan. TEL(Fax): 886-3-8881103 E-mail: ymbi@ ms1.hinet.net.

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be poorer than in those without by previous reports. Psychiatric patients with substance use disorders are reported to have increasing rates of hospitalization, utilization of acute care services, housing instability and homelessness, violent behavior, criminal and suicidal behavior, poor medication compliance and poor response to traditional treatment [2,3]. The risk factors of substance use disorder among psychiatric patients were identified as younger, male, single, lower socioeconomic status, family with a documented history of sociopathy or alcoholism [4]. The prevalence of substance use disorder is increasing in Taiwan [5], however, there have been no reports of studies evaluating the risk factors of substance use disorder in Taiwan psychiatric population. Because mood disorder patients are reported to have a higher comorbidity than other patients [6,7], our study focused on the major affective disorder patients to evaluate the risk factors for substance use disorder in Taiwan psychiatric patients, and to compare our result with similar studies in western countries.

Methods This study was conducted at Veterans General Hospital-Taipei which is located in a major urban area of Taiwan. Our sample consisted of patients with mood disorders consecutively admitted to the 62-bed psychiatric inpatient unit between April and November 1994. Patients were included if they met DSM-III-R criteria for either bipolar disorder or major depression. Patients were excluded if they were older than 65 years of age, had an equivocal axis I diagnosis or were suspected of suffering from an

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organic mental disorder or secondary to substance use disorder. Approximately one week after admission, patients were interviewed by one of the four investigators. After giving a thorough description of the study to the subjects, written informed consents was obtained. We conducted a partially modified version of the portion of the Structured Clinical Interview for (SCID) DSM-III-R which deals with substance use disorders including alcohol, sedatives-hypnotics-anxiolytics, cannabis, stimulants, opium, cocaine, hallucinogens, glue and other substances. The onset of substance use disorder was confirmed to be after the onset of mood disorder so that the possibility of substance use induced mood disorder could be ruled out. The patients were further evaluated for demographic data, ways of admission, numbers of psychiatric admission, numbers of previous against advice discharge history, utilization of emergency room, previous suicidal, violent and illegal of personal and family history. The interview was delayed if the patient was still psychotic at the time of interview. We examined the inter-rater reliability of our diagnosis of substance use disorders using SCID with a sample of 10 patients. The inter-rater reliability for the assessment of all classes of substance use disorders was high with a generalized kappa ranging from 0.85 to 1.0 between any two raters. Statistical analysis utilized the t-test for continuous variables, and the Chi-square test or exact probability test for categorical variables.

Results Twenty patients were dropped from the sample because they were too psychotic, refusing the interview or discharged before the interview. The final sample consisted of 49 patients, 17 men (33.3%) and 32 women (66.7%). The diagnosis distribution consisted of 35 cases of bipolar disorder (70.9%) and 14 cases of major depression (29.2%). The mean age of all subjects was 33.0 6 13.00 years (15 ; 62), 38 percent of these patients were married, and the average education was 11.65 6 3.36 years (0 ; 22). The first part of result was presented in Lin’s report [8]. Nine patients (18.4%) received a dual diagnosis of substance use and mood disorders. Sedative-hypnotics-anxiolytics (10.2%) was the most frequently used substances, followed by alcohol (6.1%) and stimulants (4.1%). 55.6% of the patients with substance use disorder used more than one substance. 43% of the major depression patients had a diagnosis of substance use disorder and 8.6%

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of the bipolar disorder patients had such a diagnosis. The major depression patients had significantly higher prevalence of substance use disorder than did bipolar disorder patients (p value of two-tailed Fisher’s exact test was 0.011). All the five patients with sedative-hypnoticsanxiolytics use disorder were major depression patients. The major depression patients had a significantly higher prevalence of sedative-hypnoticsanxiolytics use disorder rate than the bipolar disorder patients. (35.7% and 0% respectively, x2 5 14.046, df 5 2, p 5 0.001). All the three patients with alcohol use disorder had other substance use disorders also. The patients with substance use disorders were significantly with male-predominated (p value of two-tailed Fisher’s exact test was 0.043), with later onset age of affective disorder (t 5 22.739, df 5 47, p 5 0.009), and more frequent emergency room visits in the recent one year (t 5 21.355, df 5 8.151, p 5 0.009). (Table 1) There was no significant differences in years of education, marital status, ways of admission, numbers of admission, numbers of against advice discharge, utilization of the emergency room, previous suicide attempt, violent and illegal of personal and family history among patients with substance use disorder and those without.

Discussion Our study sample consisted of patients having substance use disorder after the onset of major affective disorder. We tried to evaluate the effect of mood disorder on substance using, and identified the associated risk factors for those major affective disorder patients to have substance use disorder. Few reported studies have compared the incidence of substance use disorder among patients with major depression and bipolar disorder. Among the schizophrenia patients, a general link between substance abuse and depressive symptoms is reported [9 –13]; adjunctive antidepressants added to neuroleptics were suggested to be useful for these substance-abusing schizophrenia patients [9]. Among the drug abusers, lifetime diagnosis of major depression was noted up to more than forty percent [14,15]. Donohue reported that elevated levels of depression were associated with increased use of drugs and alcohol [16]. Brown reported that during the cocaine and alcohol abuser treatment course, higher level of depressive symptoms were associated with greater urge to use substance in high-risk situation, and those patients with sub-

Substance Use Disorder, Mood Disorder, Risk Factor, Poly-Substance Use

Table 1. Comparison of associated factors among patients with and without substance use disorder Patients with substance use disorder (n 5 9)

Patients without substance use disorder (n 5 40)

Significance

Major depression

6 (66.7%)

8 (20%)

Male

6 (66.7%)

10 (25%)

Married Education year (years) Onset age of illness (y/o)

3 (33.3%) 12 6 3.57 35 6 13.93

p value of two-tailed Fisher’s exact test 5 0.011 P value of two-tailed of Fisher’s exact test 5 0.043 n.s. n.s. t 5 22.739, df 5 47, p 5 0.009 n.s. n.s. n.s. t 5 21.355, df 5 8.151, p 5 0.009 n.s. n.s. n.s. n.s. n.s. n.s.

Numbers of admission Admission by force Numbers of AAD Numbers of visits of ER for recent one year Personal suicidal history (1) Personal violent history (1) Personal illegal record (1) Substance use disorder of family (1) Illegal record of family (1) Psychiatric history of family (1)

17 (42.5%) 11.58 6 3.36 24.2 6 9.89

2.78 6 2.33 1 (11.1%) 0.33 6 0.71 3 6 5.12

4.28 6 4.27 2 (5%) 0.15 6 0.43 0.68 6 1.05

6 (66.7%) 6 (66.7%) 3 (33.3%) 3 (33.3%) 1 (11.1%) 6 (66.7%)

14 (35%) 15 (37.5%) 7 (17.5%) 11 (27.5%) 5 (12.5%) 18 (45%)

stance abuse relapse episode experienced more depressive symptoms during treatment [17]. Our study tried to compare the incidence of substance use disorder among major depression and bipolar disorder patients; and our result suggests that patients with major depression have a much higher prevalence of substance use disorder (43% v.s. 8.6%). The most frequently used substance was sedativehypnotics-anxiolytics. And all the five patients with sedative-hypnotics-anxiolytics use disorder were major depression patients. Those depression patients might self-medicate themselves to relieve the negative effects of mental disorder. The sedative-hypnoticsanxiolytics is frequently prescribed to the mood disorder patients by their psychiatrists. Therefore, for those patients with a high risk of substance use disorder, the prescription of sedative-hypnoticsanxiolytics should be done carefully. Muser suggested that less impaired psychiatric patients might be more prone to substance abuse [18]. Lysaker examined the severity of positive and negative symptoms for patients with and without histories of cocaine abuse; his analyses revealed that patients with cocaine-abuse exhibited less severe negative symptoms than patients without substance-abuse history [19]. O’Farrell reported that psychiatric patients who avoid the use of alco-

hol tend to be more severely ill than patients who drink either socially or abusively [20]. And Cohen and Klein also reported that severely symptomatic patients might lack the social skills and personal contacts to sustain heavy illicit drug use [21]. Ardnt reported that co-morbidity of substance abuse and schizophrenia may be explained by a common factor antecedent to both: better pre-morbid adjustment. A two-stage model is proposed to explain these findings: increased sociability increases exposure to opportunities of substance use in a subset of patients; substance onset of psychotic illness accelerates the use to a pathological level as the individual attempts to cope with the stress of the developing mental illness [22]. In our study, the male patients and patients with later onset age of affective disorder had a higher prevalence of substance use disorder. Our result supports the finding that patients with later onset age may be with better pre-morbid function and that male patients may be more capable of obtaining the substance. Substance abuse in vulnerable affective disorder patients may initiate or perpetuate their affective disorders. In this study, those patients with substance use disorder had more emergency room visits within the recent one year in comparison with other patients. This result is consistent with Leh-

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man’s finding that patients with substance use disorder visits acute care facilities more frequently [2]. These patients appear to be experiencing more withdrawal, intoxication symptoms, irritable or dysphoric mood, and violent or suicidal behaviors. In conclusion among the major affective disorder, the major depression, male patients with later onset age, with more emergency room visiting were a high risky group for substance use disorder in our study. More than half of the nine patients with substance use disorder used more than one category of substance. This finding is consistent with Lehman’s report that one third of psychiatric patients with substance use disorder were polydrug use [2]. All the three patients with alcohol use disorder in our study used other substances too. Alcohol is a nonillicit substance and is readily available in Taiwan society, patients may report the use of alcohol, but are less inclined to report the use of other substance spontaneously. Clinicians should highly suspected the possibility of poly-substance use in case of alcohol use disorder, especially for the male patients; because 83.3% of the male patients with substance use disorder were poly-substance use disorder in our study. Our overall results were consistent with previous reports of western countries. Interpretations of these findings might be limited by the small study sample size. But those patients we found to have a dual diagnosis of mood and substance use disorder is still a good sample for further research. We need to investigate the relationship of psychopathology and substance use disorder, the course and the management of both disorders in our Taiwan Chinese.

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