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Original Article |

Effects of Major Depression on Remission and Relapse of Substance Dependence FREE

Deborah Hasin, PhD; Xinhua Liu, PhD; Edward Nunes, MD; Steven McCloud, MS; Sharon Samet, MSW; Jean Endicott, PhD
[+] Author Affiliations

From the Mailman School of Public Health, Divisions of Epidemiology(Dr Hasin) and Biostatistics (Drs Hasin, Liu, and Endicott); College of Physicians and Surgeons, Department of Psychiatry (Drs Hasin and Nunes), Columbia University; and New York State Psychiatric Institute (Dr Hasin, Liu, Nunes, and Endicott and Mr McCloud and Ms Samet), New York, New York.


Arch Gen Psychiatry. 2002;59(4):375-380. doi:10.1001/archpsyc.59.4.375.
Text Size: A A A
Published online

Background  The effects of major depressive disorder (MDD) on the course of substance dependence may differ depending on the temporal relationship of depression to dependence. We investigated the effects of MDD on the outcome of substance dependence under 3 circumstances: (1) lifetime onset of MDD prior to lifetime onset of dependence onset, (2) current MDD occurring during a period of abstinence, and (3) current MDD during substance use that exceeded the expected effects of intoxication or withdrawal.

Methods  A sample of 250 inpatients with DSM-IV cocaine, heroin, and/or alcohol dependence were followed up at 6, 12, and 18 months. The Psychiatric Research Interview for Substance and Mental Disorders (PRISM) was used to make DSM-IV diagnoses. Using Cox proportional hazards models, stable remissions (those lasting at least 26 weeks) from DSM-IV cocaine, heroin, and/or alcohol dependence and from use were studied, as well as subsequent relapses of dependence and use.

Results  Patients with current substance-induced MDD were less likely to remit from dependence (adjusted hazards ratio, 0.11) than patients with no baseline MDD. A history of MDD prior to lifetime onset of substance dependence also reduced the likelihood of remission relative to the absence of such a history(adjusted hazard ratio, 0.49). Major depressive disorder during sustained abstinence predicted dependence relapse (adjusted hazards ratio, 3.07) and substance use after hospital discharge compared with those without abstinence MDD (adjusted hazards ratio, 1.45).

Conclusion  The timing of depressive episodes relative to substance dependence served as an important factor in the remission and relapse of substance dependence and substance use.

Figures in this Article

MAJOR DEPRESSIVE disorder (MDD) is common among substance abusers15 and associated with considerable psychosocial disability,68 suggesting that MDD may impede long-term remission from drug and alcohol dependence. Diagnostic problems have complicated research in this area, with efforts to resolve them largely relying on the temporal sequencing of depressive symptoms relative to substance abuse. In DSM-IV,9 major depression is "primary" if "not due to the physiological effects of a substance," a causal relationship inferred largely from timing. Primary MDD is diagnosed when symptoms precede substance use or persist during extended periods of abstinence. A DSM-IV substance-induced disorder is diagnosed when clinically significant symptoms co-occur with substance use but clearly exceed the expected effects of intoxication or withdrawal. Little prospective research is available on whether these aspects of timing affect the course of substance dependence or whether primary episodes starting prior to the lifetime onset of substance use have different effects from primary episodes occurring during periods of abstinence.

Many studies on MDD among alcoholics or drug addicts investigated lifetime depression, regardless of its timing. Rounsaville et al10 found that lifetime MDD predicted poor alcoholism outcome among males, while others11,12 did not. Given the lack of specificity about timing in these studies, inconsistencies are not surprising. Prospective studies offer clearer information. Among opiate addicts, baseline current MDD predicted subsequent heroin13 and cocaine use.14 Among alcoholic subjects, baseline MDD predicted drinking relapse.15

The lifetime order of onset of 2 disorders is fixed when the second disorder begins. Thus, a lifetime diagnosis of primary MDD with onset prior to substance dependence does not necessarily indicate current depression. However, the remitting and recurring nature of major depression is important to address in longitudinal research. Time-varying MDD predicted failure to remit from alcoholism and relapse.1618 This study did not differentiate primary and substance-induced MDD or separate prior-onset from abstinence primary depressions. Furthermore, the study did not include polysubstance abusers, whose switching of substances14 during follow-up can produce an inaccurate impression of remission if only1 substance is studied.

To address these issues, we studied the effects of MDD on substance dependence prospectively. Primary MDD beginning prior to the lifetime onset of substance dependence was not predicted to affect the outcome of current substance dependence because primary MDD usually occurs long in the past and also because of potential memory problems. Proximal abstinence and substance-induced MDD were predicted to impede remission from substance dependence. Abstinence MDD was predicted to increase the chance of relapse into substance dependence when studied in time-varying fashion, since drinking to cope with negative emotions predicts onset of alcohol dependence.19

SUBJECTS

Subjects were inpatients in a dual-diagnosis facility who were not severely psychotic or medically ill. Of 379 patients invited to participate, 349 (92%) participated in a baseline evaluation. Of these, 279 patients were of interest to the present analysis because they had a current diagnosis at baseline of DSM-IV alcohol, cocaine, and/or heroin dependence and never experienced mania or nonaffective psychosis. Of these patients, 250 (90%) participated in at least 1 follow-up interview. These are the patients described herein. Subjects were not required to meet criteria for MDD because we wanted to compare patients with and without this disorder.

The mean ± SD age of subjects was 36.9 ± 9.2 years, 66% were male, 57% were white, 15% did not complete high school, and 31% were married. At baseline, 75% met DSM-IV criteria for alcohol dependence, 58% for cocaine dependence, and 20% for heroin dependence.

PROCEDURES

Following institutional review board requirements, clinical staff identified eligible, sequentially admitted patients (who had completed acute withdrawal, if applicable) and obtained their agreement to meet with research staff, at which time the study was explained. Consenting subjects participated in a baseline Psychiatric Research Interview for Substance and Mental Disorders(PRISM).20,21 In the PRISM, the drug and alcohol sections are completed before assessment of psychiatric disorders. A PRISM test-retest study using the version for DSM-IV substance use disorders and DSM-III-R psychiatric disorders showed higher reliability than other diagnostic interviews in this type of sample.20 Lifetime onset of any disorder was defined as the age when the full disorder was first present. Age at lifetime onset of MDD was used to create a prior-onset MDD diagnosis, representing major depression with onset before the lifetime onset of alcohol, cocaine, or heroin dependence. As a lifetime diagnosis, prior-onset MDD was diagnosed regardless of current status.

In the PRISM, abstinence MDD either occurred entirely during abstinence, began at least 2 weeks prior to a period of heavy drinking and/or drug use, or began during drinking and/or heavy drug use and continued more than 4 weeks after the substance use ended. Some baseline episodes were diagnosed as abstinence MDD in subjects currently dependent on alcohol or drugs because the depressive episodes began before the current substance dependence episodes or continued into the follow-up at least 4 weeks after cessation of substance use.

Substance-induced disorders in DSM-IV occur during periods of heavy substance use with symptoms in excess of (greater than the expected effects of) intoxication or withdrawal syndromes. PRISM episodes of substance-induced MDD included those occurring entirely during periods of substance use as well as episodes ending within a month of abstinence. To systematize this diagnosis, we required the same duration and number of symptoms as required for DSM-IV primary MDD. To systematize rating symptoms in excess of expected intoxication or withdrawal effects, we used the subject's own substance-using but nondepressed experience as a reference period (most often, a period of substance use immediately preceding onset of depressed mood). Symptoms during this reference period represented the subject's expected intoxication or withdrawal effects. Symptoms that began or became clearly worse only after the onset of depressed mood were counted toward a diagnosis of substance-induced MDD. Only depressive symptoms cross-listed as DSM-IV intoxication or withdrawal symptoms for substances used by the patient were rated this way.

Subjects could report past episodes of both abstinence and substance-induced MDD. However, we studied MDD current at baseline to provide close, prospective examination of its relationship to the course of substance dependence.

Follow-up interviews were conducted 6, 12, and 18 months after baseline. Subjects were paid US $35. Subjects not interviewed when due were interviewed later whenever possible. Median length of follow-up was 91 weeks. Bias from loss to follow-up was unlikely because of the high follow-up rate and lack of differences between subjects followed up and not followed up for age (t274 = 0.29, P = .77); sex (χ21 = .004, P = .95); race (χ21 = .71, P = .40); education (χ22 = 3.52, P = .17); baseline diagnoses of DSM-IV cocaine (χ21 = .55, P = .46), heroin (χ21 = .27, P = .60), and alcohol dependence (χ21 = .038, P = .85); antisocial personality disorder (χ21 = 1.09, P= .30); prior-onset MDD (χ21 = .01, P = .94); baseline abstinence-induced MDD (χ21 = 1.14, P = .29); or baseline substance-induced MDD (χ21 = .65, P = .42).

At follow-up, subjects participated in a PRISM-L (longitudinal),21 a version of the PRISM covering the period since the previous interview. The PRISM-L includes elements of the Longitudinal Interval Follow-up Evaluation22 and also substance abuse timeline follow-back methods.23,24 PRISM-L timeline grids allow rating the course of separate conditions (including substance use, dependence, and depression) by week after study entry. Interviewers obtain a history since the previous interview and then assess the timing of alcohol and drug use, dependence and abuse symptoms, and psychiatric syndromes, referring to the timing of life events as needed. When the relative timing of substance and psychiatric disorders was unclear, semistructured probes aided systematic exploration.

Interviewers had clinical experience and received extensive, systematic training. Two supervisors with several years of research experience conducted training and supervision. They reviewed each case, conferred occasionally with members of Columbia's Department of Psychiatry and conducted weekly interviewer calibration meetings. Supervisors occasionally blindly reviewed each other's cases to ensure review consistency. After data entry and cleaning, computer programs produced diagnoses as well as the follow-up onset and offset variables.

OUTCOME MEASURES USED IN THE ANALYSIS

Remission of substance dependence was defined as 26 or more weeks during follow-up with no symptoms of dependence on heroin, cocaine, or alcohol, a definition that guarded against substance substitution and provided periods with stability.16 The start date of a remission was the first of the 26 or more required weeks. Relapse was defined as 1 or more weeks when patients experienced symptoms of DSM-IV dependence or abuse for alcohol, cocaine, or heroin dependence after the 26th week of remission from dependence.

We also investigated 3 outcomes defined by use. The first was remission for 26 or more weeks in any use of alcohol, cocaine, or heroin. The second included relapse from such remission, meaning any use of alcohol, cocaine, or heroin any time after 26 weeks or more of remission. The third was time from discharge to first use of alcohol, cocaine, or heroin.

STATISTICAL ANALYSIS

Survival analysis was used to investigate these outcomes: weeks from hospital discharge to remission of dependence and remission of use as defined already, weeks from establishment of stable remission (ie, the 26th week of remission) to subsequent relapse into dependence and relapse into use, and weeks from inpatient discharge to first use of alcohol, cocaine, or heroin after discharge. The cumulative probabilities of remission and survival curves of relapse were obtained with Kaplan-Meier estimates. Cox proportional hazard models were used to examine the effect of time-invariant and time-varying predictors. Cases were censored if they did not experience an event by the end of the follow-up, including those lost to death or follow-up. Time-invariant predictors used in the Cox models included age, sex, race, education, baseline DSM-IV diagnoses of alcohol, cocaine, and heroin dependence, antisocial personality disorder with symptoms in the year prior to the interview, and prior-onset MDD. Note that prior-onset MDD was tested independently of current MDD status. Thus, it characterized an unchanging aspect of lifetime history, regardless of current status. The models compared the effects of prior-onset MDD to the absence of such a history.

Time-varying predictors indicated the effects of change in MDD on subsequent outcome of dependence. The 2 time-varying predictors were the status of substance-induced MDD (present or absent) and the status of abstinence MDD (present or absent). These 2 types of depression were mutually exclusive at any point in time and were examined separately to determine their unique effects on remission. The basis of comparison for each type of depression was the absence of depression. Only abstinence MDD was tested in relation to relapse, since substance-induced MDD could not start during remission. Tests were 2-tailed with α = .05. Because time in a restrained environment is not remission, the follow-up period for the 138 patients hospitalized longer than a week after their baseline interview began the week of discharge.

DEPRESSION DIAGNOSES

Of the 250 patients, 37 (15%) received a lifetime diagnosis of prior-onset MDD. At baseline, 18 (49%) of 37 patients with prior-onset MDD had current abstinence MDD, while 12 (32%) of 37 had current substance-induced MDD. Thus, most patients with prior-onset MDD had a current diagnosis of MDD. The average age at onset of prior-onset MDD was 16.7 years. Since the average age of the37 patients with prior-onset MDD was 36.0 years, MDD first occurred on average19.3 years previously.

Of the 213 patients with no lifetime diagnosis of prior-onset MDD, 60(28%) had baseline diagnoses of abstinence MDD and 50 (24%) had current substance-induced MDD. Subjects with prior-onset MDD were more likely to have any current diagnosis of MDD at baseline than those without prior-onset MDD (χ21 = 4.41, P = .04) and also were more likely to have baseline abstinence MDD (χ21 = 6.16, P = .01). Those with and without prior-onset MDD did not differ on substance-induced MDD (χ21 = 1.36, P = .24). The Cox proportional hazards models (below) allowed us to study the effects of current depression controlling for prior-onset MDD.

REMISSION FROM DEPENDENCE

Among the 250 patients, 133 (53%) had a remission of all dependence symptoms lasting at least 26 weeks. Figure1 shows the Kaplan-Meier estimates of cumulative probabilities of remission from dependence. The cumulative probability curve reached its plateau of 57.1% at week 100. Prior-onset MDD decreased the likelihood of stable remission from substance dependence compared with patients without such a history (Table 1). Time-varying substance-induced MDD decreased the likelihood of stable remission from substance dependence compared with subjects with no current MDD. Abstinence MDD was not related to remission of dependence.

Place holder to copy figure label and caption
Figure 1.

Time to remission, cumulative probabilities.

Graphic Jump Location
Table Graphic Jump LocationAssociation of Major Depression With Time to Outcome of Substance Dependence or Use for 250 Patients*
REMISSION FROM USE

Among the 250 patients, 117 (47%) remitted from alcohol, cocaine, and/or heroin use for at least 26 consecutive weeks. Figure 1 shows the Kaplan-Meier estimates of cumulative probabilities of remission from use. The MDD diagnoses were not associated with time to remission in substance use (Table 1).

RELAPSE INTO DEPENDENCE

Among the 133 patients who remitted from dependence, 45 relapsed during the follow-up, leaving only 88 (35%) of the 250 patients with dependence remission from all 3 substances throughout the follow-up. Figure 2 shows the Kaplan-Meier estimates of survival probabilities of relapse into dependence. As shown in Table 1, abstinence MDD increased the risk of relapse into dependence by a factor of about 3, thus constituting an important risk factor for dependence relapse.

Place holder to copy figure label and caption
Figure 2.

Relapse after stable remission, survival curves.

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RELAPSE INTO USE

Among the 250 patients, 205 (82%) reported substance use after discharge. Of the 117 with remission of use lasting 26 weeks or more, 52 relapsed into use of alcohol, cocaine, and/or heroin, leaving only 65 (26%) of the 250 patients with stable remission from use lasting 26 weeks or more. Figure 2 shows the Kaplan-Meier estimates of cumulative probabilities of relapse into use. As shown in Table 1, neither prior-onset MDD nor abstinence MDD was associated with relapse into use. However, abstinence MDD was related to risk of use after hospital discharge. Figure 3 shows the Kaplan-Meier estimates of survival probabilities of substance use after hospital discharge.

Place holder to copy figure label and caption
Figure 3.

Time from discharge to substance use, survival curve.

Graphic Jump Location

Under all 3 temporal circumstances studied, major depression was related to the course of substance dependence, including lifetime onset prior to substance dependence, during periods of abstinence and periods of substance use when symptoms clearly exceeded the effects of intoxication and/or withdrawal. However, the effects of MDD were not uniform across the outcomes and circumstances. Prior-onset MDD was associated with reduced likelihood of remission of substance dependence, as was substance-induced MDD current at baseline. No depression variable was associated with stable remission in use. Abstinence MDD was associated with substance use after hospital discharge and relapse into dependence after a stable remission. Prior-onset MDD was not related to relapse.

The data support the DSM-IV primary and substance-induced distinctions as well as distinction between prior-onset and abstinence depressions because different types of depression were related to different aspects of outcome. While we did not predict the association of prior-onset MDD with remission from substance dependence because of its distal nature, prior-onset MDD reduced the likelihood of dependence remission even with current MDD in the model. As noted, prior-onset MDD began at about age 16 years. This early MDD may cause distinct psychosocial disability, contributing to difficulties in achieving remission from substance dependence. The time-varying course of substance-induced MDD also decreased the likelihood of dependence remission. Substance-induced MDD may place an additional proximal burden on individuals trying to recover from dependence that may interfere with activities or efforts needed to achieve sustained remission.

The effects of abstinence MDD on relapse might occur several ways. It may reduce energy needed to refrain from drug and/or alcohol use. Feeling worse during abstinence than when using substances due to depression may reduce motivation to continue abstinence efforts. Depression may lead to self-medication.25,26 Aspects of MDD may become conditioned cues for drug use, continuing to prompt drug cravings during abstinence.27 Abstinence MDD may also reflect preexisting negative thinking that presents a common risk for depression and relapse. Consistent with this, antidepressants for depression during treatment for alcoholism2832 or drug addiction29,33 improve depression and modestly improve substance abuse.

We analyzed abstinence and substance-induced MDD as separate variables, finding distinct effects. Combining them would have attenuated the ability to show an effect. This supports the utility of the DSM-IV primary vs substance-induced distinction. Our approach also supported differentiation between lifetime primary-onset and abstinence MDD. If these types of depression are truly different, combining them limits the ability to understand each one. Note that effects were found controlling for baseline dependence on all 3 substances, using an outcome defined by remission from all 3 substances. This eliminated questions about substance switching.

Several methodological limitations warrant comment. Our results were based on naturalistic findings in treated inpatients. To generalize the results, untreated subjects and different types of patients need to be studied. Also, this study did not include urine samples or informant reports. However, in the absence of sanctions, reports of drug use tend to be accurate.34 Only a few patients reported sustained remission from alcohol and/or drug use without relapse, so the scope of disclosure suggests relatively accurate reporting. Finally, we analyzed remissions lasting at least 26 weeks because we wanted periods with stability. Analyzing longer remissions would require longer follow-ups.

Investigators differ on the best outcome indicators in substance abuse research. We separated remission from relapse to study whether their predictors differed. We also analyzed dependence and use separately. Individuals can stop manifesting dependence symptoms while decreasing but not ceasing use, as indicated by the proportion of untreated drinkers with past-only alcohol dependence.35 However, in the clinical sphere, many think that a harm reduction strategy leaves patients vulnerable for relapse. Therefore, investigating predictors of sustained abstinence is important.

Difficulty diagnosing MDD in alcohol and drug patients has led to inconsistencies in the relationship of depression to substance outcome. This study presented evidence of differential effects of major depression occurring under different temporal relationships to substance dependence. Research on the reasons for differences in the effects (for example, effects of different levels or types of disability) may yield clinically useful information. We suggest that future studies on these issues be conducted.

Accepted for publication August 13, 2001.

The study was supported by grant R01 DA 08409 from the National Institute on Drug Abuse, Bethesda, Md, grant AA K02 AA00151 from the National Institute on Alcohol Abuse and Alcoholism, Bethesda, and by the New York State Psychiatric Institute.

Corresponding author and reprints: Deborah Hasin, PhD, Columbia University/New York State Psychiatric Institute, 1051 Riverside Dr, Box 123, New York, NY10032 (e-mail: dsh2@columbia.edu).

Grant  BF Comorbidity between DSM-IV alcohol use disorders and major depression: results of a national survey of adults. J Subst Abuse. 1995;7481- 497
Link to Article
Merikangas  KGelernter  C Comorbidity for alcoholism and depression. Psychiatr Clin North Am. 1990;13613- 632
Kessler  RCMcGonagle  KAZhao  SNelson  CHughes  MEshleman  SKendler  K Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;518- 9
Link to Article
Regier  DFarmer  MRae  DLocke  BKeith  SJudd  LGoodwin  F Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. JAMA. 1990;2642511- 2518
Link to Article
Hasin  DNunes  E Comorbidity of alcohol, drug and psychiatric disorders: epidemiology. Kranzler  HRounsaville  BedsDual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders. New York, NY Marcel Dekker Inc1997;1- 31
Simon  GEBarber  CBirnbaum  HGFrank  RGGreenberg  PERose  RMWang  PSKessler  RC Depression and work productivity: the comparative costs of treatment versus nontreatment. J Occup Environ Med. 2001;432- 9
Link to Article
Lin  EHVonKorff  MRusso  JKaton  WSimon  GEUnutzer  JBush  TWalker  ELudman  E Can depression treatment in primary care reduce disability? a stepped care approach. Arch Fam Med. 2000;91052- 1053
Link to Article
Judd  LLAkiskal  HSPaulus  MLeon  ACMaser  JDEndicott  JCoryell  WKunovac  JLMueller  TIRice  JPKeller  MB Psychosocial disability during the long-term course of unipolar major depressive disorder. Arch Gen Psychiatry. 2000;57375- 380
Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Rounsaville  BDolinsky  ZBabor  TMeyer  R Psychopathology as a predictor of treatment outcome in alcoholics. Arch Gen Psychiatry. 1987;44505- 513
Link to Article
O'Sullivan  KRynne  CMiller  JO'Sullivan  SFitzpatrick  VHux  MCooney  JClare  A A follow-up study on alcoholics with and without co-existing affective disorder. Br J Psychiatry. 1988;152813- 819
Link to Article
Kranzler  HRDel Boca  FKRounsaville  BJ Comorbid psychiatric diagnosis predicts three-year outcomes in alcoholics: a posttreatment natural history study. J Stud Alcohol. 1996;57619- 626
Rounsaville  BKosten  TWeissman  NKleber  H Prognostic significance of psychopathology in treated opiate addicts. Arch Gen Psychiatry. 1986;43739- 745
Link to Article
Kosten  TRounsaville  BKleber  H A 2.5-year follow-up of depression, life crises, and treatment effects on abstinence among opioid addicts. Arch Gen Psychiatry. 1986;43733- 738
Link to Article
Greenfield  SWeiss  RNuenz  LVagge  LKelly  JBellow  LMichael  J The effect of depression on return to drinking: a prospective study. Arch Gen Psychiatry. 1998;55259- 265
Link to Article
Hasin  DTsai  W-YEndicott  JMueller  TICoryell  WKeller  MB The effects of major depression on alcoholism: five-year course. Am J Addict. 1996;5144- 155
Hasin  DEndicott  JKeller  MB RDC alcoholism in patients with major affective syndromes: 2-year course. Am J Psychiatry. 1989;146318- 323
Hasin  DEndicott  JKeller  MB Alcohol problems in psychiatric patients: 5-year course. Compr Psychiatry. 1991;32303- 316
Link to Article
Carpenter  KMHasin  D A prospective evaluation of the relationship between reasons for drinking and DSM-IV alcohol-use disorders. Addict Behav. 1998;2341- 46
Link to Article
Hasin  DTrautman  KMiele  GSamet  SSmith  MEndicott  J Psychiatric Research Interview for Substance and Mental Disorders (PRISM): reliability for substance abusers. Am J Psychiatry. 1996;1531195- 1201
Hasin  DTrautman  KEndicott  J Psychiatric Research Interview for Substance and Mental Disorders: phenomenologically-based diagnosis in patients who abuse alcohol or drugs. Psychopharmacol Bull. 1998;343- 8
Link to Article
Keller  MBLavori  PWFriedman  BNielsen  EEndicott  JMcDonald-Scott  PAndreasen  NC The longitudinal interval follow-up evaluation: a comprehensive method for assessing outcome in prospective longitudinal studies. Arch Gen Psychiatry. 1987;44540- 548
Link to Article
Sobell  LSobell  MLeo  GCancilla  A Reliability of a timeline method: assessing normal drinkers' reports of recent drinking and a comparative evaluation across several populations. Br J Addict. 1988;83393- 402
Link to Article
Russell  MMarshall  JTrevisan  MFreudenheim  JChan  AMarkovic  NVana  JPriore  R Test-retest reliability of the cognitive lifetime drinking history. Am J Epidemiol. 1997;146975- 981
Link to Article
Khantzian  E The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry. 1985;1421259- 1264
Khantzian  E Self-regulation and self-medication factors in alcoholism and the addictions: similarities and differences. Recent Dev Alcohol. 1990;8255- 271
Childress  AREhrman  RMcLellan  ATMacRae  JNatale  MO'Brien  CP Can induced moods trigger drug-related responses in opiate abuse patients? J Subst Abuse Treat. 1994;1117- 23
Link to Article
Nunes  EMcGrath  PQuitkin  FStewart  JHarrison  WTricamo  EOcepek-Welikson  K Imipramine treatment of alcoholism with comorbid depression. Am J Psychiatry. 1993;150963- 965
Nunes  EQuitkin  FDonovan  SDeliyannides  DOcepek-Welikson  KKoenig  TBrady  RMcGrath  PWoody  G Imipramine treatment of opiate dependent patients with depressive disorders: a placebo-controlled trial. Arch Gen Psychiatry. 1998;55153- 160
Link to Article
McGrath  PNunes  EStewart  JGoldman  DAgosti  VOcepek-Welikson  KQuitkin  F Imipramine treatment of alcoholics with primary depression: a placebo controlled trial. Arch Gen Psychiatry. 1996;53232- 240
Link to Article
Mason  BKocis  JRitvo  ECutler  R A double-blind, placebo-controlled trial of desipramine for primary alcohol dependence stratified on the presence or absence of major depression. JAMA. 1996;275761- 767
Link to Article
Cornelius  JSalloun  IEhler  JJarrett  PCornelius  MPerel  JThase  MBlack  A Fluoxetine treatment in depressed alcoholics: a double-blind placebo controlled study. Arch Gen Psychiatry. 1997;54700- 705
Link to Article
Woody  GO'Brien  BRickels  K Depression and anxiety in heroine addicts: a placebo controlled study of doxepin in combination with methadone. Am J Psychiatry. 1975;132447- 450
Magura  SGoldsmith  DCasriel  CGoldstein  PJLipton  D The validity of methadone clients' self-reported drug use. Int J Addict. 1987;22727- 749
Grant  B Prevalence and correlates of alcohol use and DSM-IV alcohol dependence in the United States: results of the National Longitudinal Alcohol Epidemiological Survey. J Stud Alcohol. 1997;58464- 473

Figures

Place holder to copy figure label and caption
Figure 1.

Time to remission, cumulative probabilities.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Relapse after stable remission, survival curves.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Time from discharge to substance use, survival curve.

Graphic Jump Location

Tables

Table Graphic Jump LocationAssociation of Major Depression With Time to Outcome of Substance Dependence or Use for 250 Patients*

References

Grant  BF Comorbidity between DSM-IV alcohol use disorders and major depression: results of a national survey of adults. J Subst Abuse. 1995;7481- 497
Link to Article
Merikangas  KGelernter  C Comorbidity for alcoholism and depression. Psychiatr Clin North Am. 1990;13613- 632
Kessler  RCMcGonagle  KAZhao  SNelson  CHughes  MEshleman  SKendler  K Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;518- 9
Link to Article
Regier  DFarmer  MRae  DLocke  BKeith  SJudd  LGoodwin  F Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. JAMA. 1990;2642511- 2518
Link to Article
Hasin  DNunes  E Comorbidity of alcohol, drug and psychiatric disorders: epidemiology. Kranzler  HRounsaville  BedsDual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders. New York, NY Marcel Dekker Inc1997;1- 31
Simon  GEBarber  CBirnbaum  HGFrank  RGGreenberg  PERose  RMWang  PSKessler  RC Depression and work productivity: the comparative costs of treatment versus nontreatment. J Occup Environ Med. 2001;432- 9
Link to Article
Lin  EHVonKorff  MRusso  JKaton  WSimon  GEUnutzer  JBush  TWalker  ELudman  E Can depression treatment in primary care reduce disability? a stepped care approach. Arch Fam Med. 2000;91052- 1053
Link to Article
Judd  LLAkiskal  HSPaulus  MLeon  ACMaser  JDEndicott  JCoryell  WKunovac  JLMueller  TIRice  JPKeller  MB Psychosocial disability during the long-term course of unipolar major depressive disorder. Arch Gen Psychiatry. 2000;57375- 380
Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Rounsaville  BDolinsky  ZBabor  TMeyer  R Psychopathology as a predictor of treatment outcome in alcoholics. Arch Gen Psychiatry. 1987;44505- 513
Link to Article
O'Sullivan  KRynne  CMiller  JO'Sullivan  SFitzpatrick  VHux  MCooney  JClare  A A follow-up study on alcoholics with and without co-existing affective disorder. Br J Psychiatry. 1988;152813- 819
Link to Article
Kranzler  HRDel Boca  FKRounsaville  BJ Comorbid psychiatric diagnosis predicts three-year outcomes in alcoholics: a posttreatment natural history study. J Stud Alcohol. 1996;57619- 626
Rounsaville  BKosten  TWeissman  NKleber  H Prognostic significance of psychopathology in treated opiate addicts. Arch Gen Psychiatry. 1986;43739- 745
Link to Article
Kosten  TRounsaville  BKleber  H A 2.5-year follow-up of depression, life crises, and treatment effects on abstinence among opioid addicts. Arch Gen Psychiatry. 1986;43733- 738
Link to Article
Greenfield  SWeiss  RNuenz  LVagge  LKelly  JBellow  LMichael  J The effect of depression on return to drinking: a prospective study. Arch Gen Psychiatry. 1998;55259- 265
Link to Article
Hasin  DTsai  W-YEndicott  JMueller  TICoryell  WKeller  MB The effects of major depression on alcoholism: five-year course. Am J Addict. 1996;5144- 155
Hasin  DEndicott  JKeller  MB RDC alcoholism in patients with major affective syndromes: 2-year course. Am J Psychiatry. 1989;146318- 323
Hasin  DEndicott  JKeller  MB Alcohol problems in psychiatric patients: 5-year course. Compr Psychiatry. 1991;32303- 316
Link to Article
Carpenter  KMHasin  D A prospective evaluation of the relationship between reasons for drinking and DSM-IV alcohol-use disorders. Addict Behav. 1998;2341- 46
Link to Article
Hasin  DTrautman  KMiele  GSamet  SSmith  MEndicott  J Psychiatric Research Interview for Substance and Mental Disorders (PRISM): reliability for substance abusers. Am J Psychiatry. 1996;1531195- 1201
Hasin  DTrautman  KEndicott  J Psychiatric Research Interview for Substance and Mental Disorders: phenomenologically-based diagnosis in patients who abuse alcohol or drugs. Psychopharmacol Bull. 1998;343- 8
Link to Article
Keller  MBLavori  PWFriedman  BNielsen  EEndicott  JMcDonald-Scott  PAndreasen  NC The longitudinal interval follow-up evaluation: a comprehensive method for assessing outcome in prospective longitudinal studies. Arch Gen Psychiatry. 1987;44540- 548
Link to Article
Sobell  LSobell  MLeo  GCancilla  A Reliability of a timeline method: assessing normal drinkers' reports of recent drinking and a comparative evaluation across several populations. Br J Addict. 1988;83393- 402
Link to Article
Russell  MMarshall  JTrevisan  MFreudenheim  JChan  AMarkovic  NVana  JPriore  R Test-retest reliability of the cognitive lifetime drinking history. Am J Epidemiol. 1997;146975- 981
Link to Article
Khantzian  E The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry. 1985;1421259- 1264
Khantzian  E Self-regulation and self-medication factors in alcoholism and the addictions: similarities and differences. Recent Dev Alcohol. 1990;8255- 271
Childress  AREhrman  RMcLellan  ATMacRae  JNatale  MO'Brien  CP Can induced moods trigger drug-related responses in opiate abuse patients? J Subst Abuse Treat. 1994;1117- 23
Link to Article
Nunes  EMcGrath  PQuitkin  FStewart  JHarrison  WTricamo  EOcepek-Welikson  K Imipramine treatment of alcoholism with comorbid depression. Am J Psychiatry. 1993;150963- 965
Nunes  EQuitkin  FDonovan  SDeliyannides  DOcepek-Welikson  KKoenig  TBrady  RMcGrath  PWoody  G Imipramine treatment of opiate dependent patients with depressive disorders: a placebo-controlled trial. Arch Gen Psychiatry. 1998;55153- 160
Link to Article
McGrath  PNunes  EStewart  JGoldman  DAgosti  VOcepek-Welikson  KQuitkin  F Imipramine treatment of alcoholics with primary depression: a placebo controlled trial. Arch Gen Psychiatry. 1996;53232- 240
Link to Article
Mason  BKocis  JRitvo  ECutler  R A double-blind, placebo-controlled trial of desipramine for primary alcohol dependence stratified on the presence or absence of major depression. JAMA. 1996;275761- 767
Link to Article
Cornelius  JSalloun  IEhler  JJarrett  PCornelius  MPerel  JThase  MBlack  A Fluoxetine treatment in depressed alcoholics: a double-blind placebo controlled study. Arch Gen Psychiatry. 1997;54700- 705
Link to Article
Woody  GO'Brien  BRickels  K Depression and anxiety in heroine addicts: a placebo controlled study of doxepin in combination with methadone. Am J Psychiatry. 1975;132447- 450
Magura  SGoldsmith  DCasriel  CGoldstein  PJLipton  D The validity of methadone clients' self-reported drug use. Int J Addict. 1987;22727- 749
Grant  B Prevalence and correlates of alcohol use and DSM-IV alcohol dependence in the United States: results of the National Longitudinal Alcohol Epidemiological Survey. J Stud Alcohol. 1997;58464- 473

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