Drug Abuse and Mental Illness: Which Comes First?

Drug Abuse and Mental Drug Abuse and Mental Illness: Which Comes First?Illness: Which Comes First?

Jake M Najman, PhD FASSAJake M Najman, PhD FASSAProfessor and DirectorProfessor and Director

Major focus on researchMajor focus on research

Does substance (licit and illicit) use lead to Does substance (licit and illicit) use lead to mental illness?mental illness?

Need to test for the possibility that Need to test for the possibility that substance use represents ‘self-medication’ substance use represents ‘self-medication’ i.e. Emotionally disturbed individuals who i.e. Emotionally disturbed individuals who use drugs for relaxation and reliefuse drugs for relaxation and relief

What needs to be knownWhat needs to be known

Age of onsetAge of onset

Duration of disorderDuration of disorder

Duration to first and subsequent recurrences Duration to first and subsequent recurrences

Frequency of recurrenceFrequency of recurrence

Factors which determine onsetFactors which determine onset

Factors which determine recurrencesFactors which determine recurrences

Natural history over the life courseNatural history over the life course

Impact of help seeking and treatment on the Impact of help seeking and treatment on the natural historynatural history

Disorders which are the focus of Disorders which are the focus of our researchour research

Alcohol abuse/dependenceAlcohol abuse/dependence

Nicotine abuse/dependenceNicotine abuse/dependence

Illicit drug use disorders Illicit drug use disorders – CannabisCannabis– AmphetaminesAmphetamines

Previous population based research using Previous population based research using the Composite International Diagnostic the Composite International Diagnostic Interview (CIDI) has found high Interview (CIDI) has found high frequencies of mental illness in the frequencies of mental illness in the population and remarkably young ages of population and remarkably young ages of onset for many mental illnessesonset for many mental illnesses

National Comorbidity Survey Replication (NCSR Kessier et al, 2005)

National representative sample of persons 18yrs + in the USA

Face-to-face interviews. Feb 2001 – April 2003

Diagnostic assessment using the World Mental Health Composite International Diagnostic Interview (WMH-CIDI)

Produces DSM-IV and ICD-10 Diagnoses

Retrospective age-of-onset reports

“Can you remember your exact age the very first time you HAD THE SYNDROME?”

For those who answered NO = probe of time found eg. “Was it before you started school?”

Upper end of bound used if bound was selected.

Age of Onset of CIDI-II Disorders (NCSR Kessler et al, 2005)

Onset

Percentiles

Any Anxiety Disorder

Any Depressive

Disorder

Any Impulse Control

Disorder

Any Substance

use Disorder

5 5yrs 11yrs 5yrs 15yrs






•Began in January 1981 - December 1983.• All public patients enrolled at their First

(Obstetrical) Clinic Visit (FCV).• In all, 8556 consecutive patients invited to

participate; 8458 agreed to participate in the study.• Of the 8,458 agreeing to participate in the study,

about 7,332 infants were discharged alive from the study hospital. There were some 170 miscarriages, and 300 mothers moved to another location for the birth.

Mater-University of Queensland Study of Pregnancy (MUSP)

At entry• Questionnaire administered average 18 weeks

gestation at first clinic visit

At birth• Questionnaire administered 3-5 days after the birth

At 6 months• Questionnaire administered via telephone follow-up

• About 90 per cent of mothers giving birth responded to this questionnaire

At 5 years• Questionnaire administered in hospital or at home to mothers• Child assessed by Paediatric Researcher• About 70 per cent of mothers giving birth responded to this questionnaire

At 14 years• Questionnaire administered in hospital or at home to mother and child• Child assessed by Paediatric Researcher• About 70 per cent of mothers and children participated in this phase

At 21 year F/UAt 21 year F/U

Questionnaire administered at home to mother Questionnaire administered at home to mother and youthand youth

Physical assessmentsPhysical assessments

– Blood pressureBlood pressure

– Lung functionLung function

– PhysiquePhysique

– CIDI – computer administeredCIDI – computer administered

MUSP27 is currently underway. It involves MUSP27 is currently underway. It involves a 27 year follow up of the mothers with a a 27 year follow up of the mothers with a focus on mental and physical health of the focus on mental and physical health of the women as they progress through women as they progress through menopausemenopause

MUSP30 is scheduled to begin January MUSP30 is scheduled to begin January 2011. It is a 30 year follow up of the 2011. It is a 30 year follow up of the children with a focus on cardiovascular children with a focus on cardiovascular disease, metabolic syndrome, mental disease, metabolic syndrome, mental illness and substance use and abuse. It illness and substance use and abuse. It involves the collection of blood samples involves the collection of blood samples and a study gene-environment and a study gene-environment interactions.interactions.

MUSP FindingsMUSP Findings

DSM-IV Diagnoses at 21yr DSM-IV Diagnoses at 21yr Follow-upFollow-up

Lifetime(%)

12 months (%)

Anxiety 25.0 19.0

Depression 21.5 10.7

Alcohol use disorder 27.9 14.1

Nicotine use disorder 16.6 12.5

Cannabis use disorder 21.9 9.0

Amphetamine use disorder 4.1 1.4

*Sample sizes vary between 2,549 – 2,572.

CIDI-II – Anxiety Disorders at 21 Yr Follow-up – MUSP

Age of Onset - Anxiety

Mean = 11.3 yrs

N %

10 yrs or less 287 44.6

11-12 yrs 81 12.6

13-14 yrs 95 14.8

15-16 yrs 74 11.5

17-18 yrs 60 9.3

19-20 yrs 41 6.4

21-22 yrs 5 0.8

643

CIDI-II –Depression at 21 Yr Follow-up – MUSP

Age of Onset - Depression

Mean = 16.6 yrs

N %

10 yrs or less 17 3.1

11-12 yrs 18 3.3

13-14 yrs 70 12.7

15-16 yrs 132 24.0

17-18 yrs 180 32.7

19-20 yrs 112 20.4

21-22 yrs 21 3.8

550

CIDI-II – Alcohol Use Disorder at 21 Yr Follow-up – MUSP

Age of Onset - Alcohol AbuseMean = 17.3 yrs

N %


11-12 yrs - -

13-14 yrs 49 6.9

15-16 yrs 160 22.5

17-18 yrs 346 48.6

19-20 yrs 144 20.2

21-22 yrs 12 1.7

712

CIDI-II – Nicotine Use Disorder at 21 Yr Follow-up – MUSP

Age of Onset - Nicotine Dependence

(Mean = 17.5 yrs)

N %


11-12 yrs 0 -

13-14 yrs 16 4.9

15-16 yrs 46 14.0

17-18 yrs 139 42.2

19-20 yrs 109 33.4

21-22 yrs 17 5.2

329 100

CIDI-II – Cannabis Use Disorder at 21 Yr Follow-up – MUSP

Age of Onset - Cannabis Abuse(Mean = 16.4 yrs)

N %


11-12 yrs 3 0.6

13-14 yrs 48 9.6

15-16 yrs 168 33.6

17-18 yrs 221 44.2

19-20 yrs 53 10.6

21-22 yrs 6 1.2

500 100

CIDI-II – Amphetamine Use Disorder at 21 Yr Follow-up – MUSP

Age of Onset - Amphetamine Abuse

(Mean = 17.4 yrs)

N %


11-12 yrs - -

13-14 yrs 2 1.9

15-16 yrs 24 22.9

17-18 yrs 49 46.7

19-20 yrs 26 24.8

21-22 yrs 2 1.9

105 100

Mean age of onsetMean age of onset

N Years

Anxiety disorder 643 11.3

Cannabis use disorder 500 16.4

Depression disorder 550 16.6

Alcohol use disorder 712 17.3

Amphetamine use disorder 105 17.4

Nicotine use disorder 329 17.5

What occurs first; mental illness (anxiety What occurs first; mental illness (anxiety or depression) or substance use or depression) or substance use disorders?disorders?

By age 21, 34.1% of those with By age 21, 34.1% of those with anxiety disorder and 30.2% of those anxiety disorder and 30.2% of those with alcohol disorder have had both with alcohol disorder have had both

disordersdisorders

631 with Anxiety712 with Alcohol

81.3% Anxiety preceded Alcohol81.3% Anxiety preceded Alcohol

7.5% Anxiety and Alcohol in same year7.5% Anxiety and Alcohol in same year

11.2% Alcohol preceded anxiety 11.2% Alcohol preceded anxiety

214 with Anxiety and Alcohol

By age 21, 31.5% of those with By age 21, 31.5% of those with anxiety disorder and 47.6% of those anxiety disorder and 47.6% of those with nicotine disorder have had both with nicotine disorder have had both

disordersdisorders

641 with Anxiety424 with Nicotine

82.6% Anxiety precedes Nicotine82.6% Anxiety precedes Nicotine

7.2% Anxiety and Nicotine in same year7.2% Anxiety and Nicotine in same year

10.3% Nicotine precedes Anxiety 10.3% Nicotine precedes Anxiety

195 with Anxiety and Nicotine

By age 21, 28.8% of those with an By age 21, 28.8% of those with an anxiety disorder and 32.5% of those anxiety disorder and 32.5% of those with a cannabis disorder have had with a cannabis disorder have had

both disordersboth disorders

628 with Anxiety557 with Cannabis

180 with Anxiety and Cannabis Use

77.2% Anxiety precedes Cannabis77.2% Anxiety precedes Cannabis

7.2%Anxiety precedes Cannabis in same 7.2%Anxiety precedes Cannabis in same yearyear

15.6% Cannabis precedes Anxiety15.6% Cannabis precedes Anxiety

By age 21, 4.3% of those with an By age 21, 4.3% of those with an anxiety disorder and 25.7% of those anxiety disorder and 25.7% of those with an amphetamine disorder have with an amphetamine disorder have

experienced both disordersexperienced both disorders

629 with Anxiety105 with Amphetamine

27 with Anxiety and Amphetamine Use

77.8% Anxiety precedes Amphetamine Use77.8% Anxiety precedes Amphetamine Use

3.7% Anxiety precedes Amphetamine Use same 3.7% Anxiety precedes Amphetamine Use same yearyear

18.5% Amphetamine Use precedes Anxiety 18.5% Amphetamine Use precedes Anxiety

Anxiety almost always Anxiety almost always precedesprecedes::

Alcohol disorderAlcohol disorder

Nicotine disorderNicotine disorder

Cannabis use disorderCannabis use disorder

Amphetamine use disorderAmphetamine use disorder

546 with Depression546 with Depression711 with Alcohol 711 with Alcohol

By age 21, 36.1% of those with By age 21, 36.1% of those with depression and 27.7% of those with depression and 27.7% of those with an alcohol disorder have had both an alcohol disorder have had both

disordersdisorders

40.1% Depression precedes Alcohol40.1% Depression precedes Alcohol

23.9% Depression and Alcohol in same 23.9% Depression and Alcohol in same yearyear

36.0% Alcohol precedes Depression36.0% Alcohol precedes Depression

197 with Depression and Alcohol

550 with Depression550 with Depression421 with Nicotine421 with Nicotine

By age 21, 30.2% of those with By age 21, 30.2% of those with depression and 39.4% of those with a depression and 39.4% of those with a

nicotine disorder have had both nicotine disorder have had both disordersdisorders

50.6% Depression precedes Nicotine50.6% Depression precedes Nicotine

21.1% Depression and Nicotine in same 21.1% Depression and Nicotine in same yearyear

28.3% Nicotine precedes Depression28.3% Nicotine precedes Depression

166 with Depression and Nicotine

545 with Depression545 with Depression557 with Cannabis557 with Cannabis

By age 21, 31.7% of those with By age 21, 31.7% of those with depression AND 31.1% of those with depression AND 31.1% of those with

cannabis disorders have cannabis disorders have experienced both disordersexperienced both disorders

173 with Depression and Cannabis Use

37.0% Depression precedes Cannabis37.0% Depression precedes Cannabis

19.1% Depression precedes Cannabis 19.1% Depression precedes Cannabis same yearsame year

43.9% Cannabis precedes Depression 43.9% Cannabis precedes Depression

545 with Depression545 with Depression105 with Amphetamine Use 105 with Amphetamine Use

By age 21, 6.8% of those with By age 21, 6.8% of those with depression AND 35.2% of those with depression AND 35.2% of those with

an amphetamine disorders have an amphetamine disorders have experienced both disordersexperienced both disorders

37 with Depression and

Amphetamine Use

35.1% Depression precedes Amphetamine 35.1% Depression precedes Amphetamine

32.4% Depression precedes Amphetamine 32.4% Depression precedes Amphetamine same yearsame year

32.4% Amphetamine precedes Depression 32.4% Amphetamine precedes Depression

Generally depression precedes:Generally depression precedes:

Alcohol use disorderAlcohol use disorder

Nictotine use disorderNictotine use disorder

Depression occurs equally before Depression occurs equally before and after the following disorders:and after the following disorders:

Cannabis use disorderCannabis use disorder

Amphetamine use disorderAmphetamine use disorder

Summary of findingsSummary of findings

All mental disorders commonly have a All mental disorders commonly have a young age of onsetyoung age of onset

Where co-occurrence with anxiety, then Where co-occurrence with anxiety, then anxiety tends to precede substance abuse anxiety tends to precede substance abuse disorders – Is this self-medication?disorders – Is this self-medication?

Summary of findings (cont’d)Summary of findings (cont’d)

Where co-occurrence with depression, Where co-occurrence with depression, then depression tends to precede alcohol then depression tends to precede alcohol and nicotine disorder; but often occurs and nicotine disorder; but often occurs before and after cannabis and before and after cannabis and amphetamine use disordersamphetamine use disorders

To detect the negative mental health To detect the negative mental health consequences of substance abuse consequences of substance abuse disorders, need to adjust for previous disorders, need to adjust for previous mental health problemsmental health problems

ConclusionsConclusions

There is a high level of use of substance by There is a high level of use of substance by those who have a pre-existing mental illness.those who have a pre-existing mental illness.

It is as likely that mental illness leads to It is as likely that mental illness leads to substance use as substance use leads to mental substance use as substance use leads to mental illness.illness.

For some mental illnesses and substances there For some mental illnesses and substances there is high co-occurrence e.g. anxiety, depression is high co-occurrence e.g. anxiety, depression and smoking which for others a low level of co-and smoking which for others a low level of co-occurrence e.g. Anxiety, depression and occurrence e.g. Anxiety, depression and amphetamine useamphetamine use

Drug Abuse and Mental Illness: Which Comes First?

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