Psychosomatics 43:405-412, October 2002
© 2002 The Academy of Psychosomatic Medicine
Problem Substance Use Among Depressed Patients in Managed Primary Care
Carol A. Roeloffs, M.D., M.S.H.S.,
Kenneth B. Wells, M.D., M.P.H.,
Douglas Ziedonis, M.D., M.P.H.,
Lingqi Tang, Ph.D., and
Jürgen Unützer, M.D., M.P.H.
Received Nov. 12, 2001; revision received April 11, 2002; accepted April 26, 2002. From the Department of Psychiatry and Behavioral Sciences, UCLA Neuropsychiatric Institute; RAND, Santa Monica, Calif.; and the Robert Wood Johnson Medical School, New Brunswick, N.J. Address reprint requests to Dr. Roeloffs, UCLA Neuropsychiatric Institute, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024; croeloff{at}ucla.edu (e-mail).
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ABSTRACT
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This study identifies characteristics associated with problem substance use among 1,187 patients with either depressive symptoms (44%) or depressive disorders (56%) in primary care clinics of six managed care organizations. Sedative misuse (reported by 14% of all patients) was associated with greater wealth, social phobia, and misuse of prescription opioids. Cannabis use (11%) was associated with younger age, male gender, single marital status, white ethnicity, less education, recurrent depression, agoraphobia, and hazardous alcohol use. Hazardous drinking (11%) was significantly associated with younger age, male gender, single marital status, and cannabis use. Greater understanding of substance use problems in primary care patients with depressive symptoms and disorders may aid efforts to more quickly identify, educate, and provide services for those in need.
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INTRODUCTION
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In the past 10 years, there has been increasing concern about high rates of depression and low rates of identification and treatment of depression in primary care.1–3 Co-occurring substance use disorders are thought to complicate diagnosis and treatment of depression and increase the risk of suicide.4–7 Patients with co-occurring substance use disorders are typically excluded from research studies on depression. Little is known about the extent or implications of co-occurring substance abuse and depression in primary care, in which half of all mental health treatment occurs.
Alcohol and drug abuse are relatively common but often not recognized in primary care settings. Although prevalence rates are difficult to compare because of differing definitions and instruments, about one in five medical patients probably has an alcohol use disorder.8 Coulehan et al.9 found that 14% of primary care patients had a current DSM-III substance abuse problem, but only 40% had the problem identified by their primary care clinician. Of those who were substance abusers, 45% abused only alcohol, 24% only drugs—mostly barbiturates, benzodiazepines, amphetamines, and opioids—and 31% abused both alcohol and drugs. Epidemiological studies have shown that individuals with one substance use disorder are more likely to have a secondary addictive disorder and that individuals with substance use disorders have higher rates of major depression, medical illness, and anxiety disorders than those who do not.10–15 Almost nothing is known about the prevalence of substance use disorders in primary care patients with depressive symptoms or depressive disorders.
In this study, we estimated the prevalence of problem alcohol and drug use among primary care patients with either depressive symptoms or depressive disorders and described the characteristics of patients with hazardous drinking, prescription drug misuse, and illicit drug use, focusing on the three most common drugs reported—cannabis, sedatives/tranquilizers, and prescription opioids.16 To date, physicians have been most concerned with individuals with severe substance abuse or dependence and less with identification or early intervention in individuals who have had some problems related to their substance use or are at risk for substance-related problems.17 However, physicians treating depressed individuals should consider the implications of any drug use on diagnosis and treatment choice. Low rates of identification and treatment indicate the importance of improving screening and treatments for depression and substance use in primary care settings. This is the first study of which we are aware that used a large, multisite database of primary care patients with either depressive symptoms or depressive disorders to study characteristics of patients at risk for alcohol and drug problems. On the basis of the literature, we hypothesized that rates of problem substance use would be moderately high and would be associated with either depressive symptoms or depressive disorders and certain demographic factors, particularly gender and socioeconomic indicators.
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METHOD
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Design
A cross-sectional survey was administered as part of an intervention study to improve quality of care for depression and was conducted at six national managed primary care sites.16
Setting
The participating rural, suburban, and urban clinics of six managed care organizations were geographically diverse, served a high proportion of Mexican Americans, and included public, private, staff, and network practice models.
Patients
A total of 1,356 patients with depressive symptoms were recruited by screening consecutive visitors to the participating primary care clinics. Eligible patients were 18 years or older, spoke English or Spanish, considered the clinic their primary source of medical care, and had insurance that covered care from behavioral health care providers of the interventions. All patients with medical and psychiatric comorbidities were eligible.
A self-report patient depression screening questionnaire was administered to 27,332 consecutive patients. Patients were identified as "depressed" if they scored positively on the World Health Organization Composite International Diagnostic Interview 2.1, 12-month version,18 for any "stem" item for major depression or dysthymia in the past 12 months and were positive for any item in the past month as well. The positive predictive value for the stem items against the full Composite International Diagnostic Interview is 55%, a high value for a screening device and suggestive of good concordance.16 A total of 14% (N=3,918) of the 27,332 patients screened met eligibility criteria, and 1,356 patients enrolled in the 2-year longitudinal study. Institutional review board approval was obtained for all sites, and all participants signed informed consent after receiving a complete description of the study. Enrolled patients completed the full affective disorders section of the Composite International Diagnostic Interview (100% response rate) and a baseline patient assessment questionnaire (88% response rate). According to screening measures, enrolled patients were similar in physical and mental health status to the nonenrolled patients but were slightly older, better educated, and more likely to be female.16 We included all patient assessment questionnaire respondents with available data on substance misuse (N=1,187) in our analyses.
Measures
Hazardous drinking was defined as a "quantity or pattern of alcohol consumption that places patients at risk for adverse health events, ... (e.g., physical or psychological harm)."19 Hazardous drinking was measured with the Alcohol Use Disorders Identification Test, a 10-question tool for detecting individuals at risk for alcohol use problems. A cutoff score of 8 of 40 has a sensitivity of 96% and specificity of 98% for hazardous alcohol consumption.19–22 Data on drug misuse were elicited by asking respondents if they had used any drug in the past 6 months "without a doctor's prescription," "in greater amounts or more often than prescribed," or "for a reason other than a doctor said you should use them." Drug categories were cannabis (marijuana or hashish), sedatives and tranquilizers (including barbiturates and quaaludes), heroin, opiates/opioids other than heroin, cocaine and crack, amphetamines, psychedelics, and inhalants. Nicotine use was not assessed. This item was modified from a validated substance abuse screener.23
The initial screening questionnaire provided demographic information (age, gender, marital status, ethnicity, and education). The baseline interview collected financial information to determine individual total wealth. The number of chronic medical illnesses (asthma, diabetes, hypertension, arthritis, physical disability, lung disease, cancer within the last 3 years, neurological condition, stroke or paralysis, congestive heart failure, angina or coronary artery disease, any heart disease, back problems, ulcer, chronic bowel condition, thyroid disease, kidney failure, vision problems, migraine headaches) was also assessed in the initial screening by self-report. Major depression, dysthymia, and anxiety disorders (panic disorder, agoraphobia, social phobia, generalized anxiety disorder) in the past 12 months were assessed with the Composite International Diagnostic Interview. Recurrent depression was defined as two or more prior episodes of depression.
Statistical Analyses
We calculated the prevalence of individual substance misuse and calculated weighted percentages, weighting to correct for the probability of enrollment, attrition, and survey response and thus reflected all screened eligible patients. To determine characteristics of individuals with problem drinking, cannabis use, sedative/tranquilizer use, or opiate misuse, we conducted bivariate and logistic regression analyses. Missing data at the item level were imputed with a multiple imputation method.24–26 Outcome variables were not imputed. SAS version 6.12 was used for data management, and STATA version 6 was used for statistical analyses.
Separate logistic regressions for determinants of hazardous drinking, cannabis use, sedative/tranquilizer use, and opioid misuse each included age, gender, ethnicity, wealth, education, and marital status. The number of chronic medical disorders (zero, one, two, or three or more) was used to control for severity of comorbid medical illness. Presence of a major depressive disorder was included to control for severity of depressive symptoms. An indicator for the managed care organization and a variable for a delay in return of the baseline questionnaire were also included as design variables. Other clinical covariates were included only if significant (p<0.10) in the bivariate analysis. The final regression model for hazardous drinking included cannabis use and sedative misuse. For cannabis use, the regression included agoraphobia, recurrent depression, prescription opioid misuse, sedative/tranquilizer misuse, and hazardous drinking. For sedative misuse, it included generalized anxiety disorder, social phobia, recurrent depression, cannabis use, opioid misuse, and hazardous drinking. For opioid misuse, it included social phobia and sedative misuse.
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RESULTS
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Characteristics of Analytic Group
Our study group (N=1,187) was 73% female and 26% Hispanic (Table 1). Ages ranged from 18 to 90 years, with a median age of 43. A total of 56% had a diagnosis of major depression or dysthymia, while 44% had depressive symptoms but did not meet criteria for dysthymia or major depression. A total of 42% had comorbid panic disorder, generalized anxiety disorder, agoraphobia, or social phobia. Weighted percentages were similar to nonweighted percentages; therefore, they were not reported in the tables.
Prevalence of Problem Substance Use
Table 2 presents unadjusted frequencies of single and multiple substance misuse. A total of 27% reported use of at least one illicit drug or problem use of a prescription drug in the past 6 months. Problem use of prescription drugs was more common than use of illicit drugs (19% versus 12%). Sedatives and tranquilizers were the most common prescription drug class misused (14%), followed by opiates (7%) and amphetamines (3%). Marijuana and hashish (11%) were the most common illicit drugs used; 2% used another illicit drug. A total of 11% of the group had a pattern of hazardous drinking, 6% had both hazardous drinking and used at least one drug, and 9% used multiple drugs.
Characteristics Associated With Problem Substance Use
After controlling for sociodemographic and clinical variables (Table 3), age, gender, marital status, ethnicity, education, recurrent major depression, agoraphobia, and hazardous drinking significantly predicted the use of cannabis. Older (odds ratio=0.26, p<0.001) and female patients (odds ratio=0.46, p<0.001) and those with less than a high school education (odds ratio=0.35, p=0.02), some college (odds ratio=0.59, p=0.06), or 4 or more years of college or graduate education (odds ratio=0.31, p<0.001) had lower odds of cannabis use. Single patients (odds ratio=2.19, p=0.01) had significantly higher rates of cannabis use. Patients of Hispanic origin (odds ratio=0.39, p=0.01) had lower rates of cannabis use than white users. Patients with recurrent major depression (odds ratio=1.80, p=0.03), agoraphobia (odds ratio=1.91, p=0.03), or problem alcohol use (odds ratio=4.84, p<0.001) also had greater odds of cannabis use.
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TABLE 3. Demographic and Clinical Characteristics Related to Problem Drinking and Drug Use Among Depressed Primary Care Patients
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Individuals in the wealthiest quartile reported higher rates of sedative prescription drug misuse than individuals in quartiles with less wealth (odds ratio=0.54, p=0.05; odds ratio=0.58, p=0.05; and odds ratio=0.40, p<0.003). Individuals with social phobia (odds ratio=2.17, p<0.001) and prescription opioid use problems (odds ratio=6.78, p<0.001) reported higher rates of sedative misuse.
Factors that were significantly associated with opioid misuse included having three or more chronic illnesses (odds ratio=4.54, p=0.01) and misuse of prescription sedatives (odds ratio=7.13, p<0.001). Older (odds ratio=0.43, p<0.001) and female (odds ratio=0.31, p<0.001) participants reported lower rates of problem drinking. Separated, widowed, and divorced patients (odds ratio=2.10, p=0.01) and those using cannabis (odds ratio=5.09, p<0.001) reported higher rates of problem drinking. Results significant in more than one category of substance misuse are reported in Table 3.
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DISCUSSION
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More than one-quarter of the primary care patients with either depressive symptoms or depressive disorders in our group reported some prescription drug misuse or illicit drug use, and 11% reported problem drinking. The rates of illicit drug use (12%) and marijuana use (11%) in this group are similar to rates found in the National Household Survey of Drug Abuse.12 The rate of hazardous drinking we found (11%) fell within the range for hazardous drinking reported in studies of both community and medical outpatient samples (4%–29%).8 Prescription drug misuse in this study was notably higher than in the community (19.3% compared to 2.8%, respectively).12 A plausible reason for the higher proportion of sedative misuse is the greater exposure of primary care patients to medications that are commonly prescribed for sleep or anxiety symptoms, common symptoms of depression. Overuse of sedatives among depressed patients was identified in the medical outcomes study as an important area for quality improvement. Sedatives, opioids, and marijuana can worsen depressive symptoms and lead to cognitive impairment, falls, or drug dependence.1
The most consistent predictor of problematic substance use in this study was misuse of other prescription drugs or illicit drugs. Among primary care patients with depressive symptoms or disorders, hazardous drinking increased the odds of cannabis use; prescription opioid misuse and hazardous drinking increased the odds of sedative misuse; and sedative misuse increased the odds of opiate misuse. High rates of polysubstance abuse have been reported for community and specialty treatment samples. The Epidemiologic Catchment Area (ECA) Study found that 72% of those with drug use disorders had at least one co-occurring psychiatric disorder—mostly other substance use disorders.27 Our results suggest that concurrent use of multiple substances is also characteristic of primary care patients with either depressive symptoms or depressive disorders, suggesting the need for greater vigilance in screening for multiple substance use.
We found that social phobia was significantly associated with sedative misuse and agoraphobia with cannabis use, indicating the importance of screening for drug use when anxiety is present. Since sedatives are often used to treat anxiety disorders, high levels of misuse indicate a need for improved monitoring and follow-up of patients with anxiety disorders who are given prescriptions for sedative medication. Substance use may follow anxiety disorders, which have an early onset and may indicate attempts at self-medication.13 The diagnosis of an anxiety disorder, therefore, presents an important opportunity for prevention of substance use among adolescents and young adults. Our findings also reinforce other studies suggesting that depressed patients with comorbid anxiety disorders have poor health-related quality of life and are at high risk for serious behavioral problems with significant social consequences, such as substance use and suicide.4,5,13,27,28
We did not observe a significant association between severity of depressive disorder and substance problems but did find that recurrent depressive disorder was associated with cannabis use. In previous studies, lifetime substance abusers have shown a high prevalence of chronic medical conditions.14 We found that the number of chronic illnesses was associated with opiate misuse, likely reflecting greater exposure to analgesic medication or psychosocial difficulties due to pain or illness. However, we did not find an association between number of chronic medical illnesses and hazardous drinking, cannabis use, or sedative misuse.
We also found that demographic characteristics associated with substance misuse varied with each substance and, in some cases, from expectations of use derived from community surveys, such as the ECA, the National Comorbidity Survey, and the National Household Survey on Drug Abuse. This demographic diversity of primary care patients with depressive symptoms or depressive disorders and co-occurring substance misuse emphasizes the need for clinicians to broadly screen all depressed patients for substance misuse, including patients with only a few depressive symptoms.
Despite recommendations by depression practice guidelines to screen all depressed patients for substance use, studies suggest that substance abuse is often not recognized in primary care.9,15,29–31 In addition, our findings suggest that primary care physicians should go beyond the guidelines by screening for substance misuse in the presence of any depressive symptoms. We believe this is a new, important addition to the literature. Physicians' attitudes and knowledge of substance abuse and other mental illness affect their ability to recognize substance abuse, but even if physicians are aware of the problem, primary care settings impose serious time constraints and can present difficulties ensuring confidentiality, which can complicate the diagnosis and treatment of these problems in primary care.32,33 However, many patients look to their primary care provider for treatment of mental health and substance use problems rather than seeking care from a mental health specialist.34 Brief physician advice in primary care settings has been shown to be effective for problem drinking; this may be an adequate intervention for substance misuse, especially in the context of depressive symptoms or depressive disorders. In addition, some primary care physicians are more involved in addiction treatment; there is recent research that has demonstrated the efficacy of primary-care-based treatment of opioid dependence with buprenorphine.35,36 Several models of collaborative mental health and primary care exist, which can include, depending on local resources and needs, on- or off-site consultation or referral with a mental health provider, substance abuse specialist, or dual-diagnosis clinic.37
A number of study limitations suggest caution in the interpretation of our findings. Patient information was obtained by self-report, which may lead to underreporting of substance use. As managed care organizations were not randomly selected, the generalizability to other managed care settings is not clear. However, the organizations were diverse and included public and private, rural and urban, managed, fee-for-service, and capitated practice settings. Furthermore, patients were diverse clinically and demographically. Although patient enrollment and response rates were moderate, our data were weighted to compensate for selection and survey response and thus reflected the entire eligible population. Consecutive sampling may have overselected sicker clinic visitors who may have had more comorbid conditions. These cross-sectional data do not provide information on the temporal relationships between depression and comorbid conditions and do not permit attribution of causality.
In summary, our findings suggest that problem substance use is common among patients with either depressive symptoms or depressive disorders in managed primary care clinics. Problem drinking, cannabis abuse, and the misuse of prescription sedatives and opioids are particularly common and occur across different clinical and demographic groups of primary care patients, often contrary to expectations based on community surveys. Future research should explore methods of improving the quality of primary care screening procedures for substance abuse and depression and clarify the impact of comorbid drug misuse on the treatment of depression and its outcomes. Efforts to identify effective strategies to manage such comorbidity within the context of managed primary care practice, such as the use of collaborative models of care, may have great promise in improving care for depression and substance use problems.37 Last, in light of the prevalence and social costs of both depression and substance use, policy makers should increase efforts to decrease stigma around accessing mental health and substance abuse services and increase availability of effective treatments.
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ACKNOWLEDGMENTS
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Supported by grants from NIMH (MH-54623 and MH-00990) and the Agency for Health Care Policy and Research (HS-08349). The authors thank Arlene Fink, Ph.D., for comments on earlier drafts and Ruth Klap, Ph.D., Diana Liao, M.P.H., and Jennifer Liu, B.S., for statistical assistance.
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ABSTRACT
INTRODUCTION
