SUPPLEMENTsion within their client groups, there arelikely to be more single-issue and polydrug-using clients seeking adjunctive mentalhealth treatment from GPs. Most individualsseeking treatment for drug use disorders areat the more severe end of the AOD spec-trum.6-8 As yet, there are few Australian data

ParticipantsNinety-five individuals (56 men [mean age =38.18 years; SD, 8.27 years] and 39 women[mean age = 36.64 years; SD, 9.83 years])attending outpatient AOD services partici-pated in the study. Most participants (81%)

Measures Composite International Diagnostic Inter-view (CIDI), version 2.1:10 we used this diag-nostic measure (for mood and substance usedisorders) to assess mental disorders andprovide diagnoses according to definitionsorders, including prescription of psycho-tropic drugs, focused psychologicalstrategies and referral to specialists (eg, psy-chologists) using the Better Outcomes inMental Health Care and Better Access toMental Health Care initiatives.3-5

GPs may be more familiar and comfort-

tal hpeopWe edifferorderpatiepatieS60

to assist GPs in understanding the type andseverity of AOD and high-prevalence mentalhealth problems in patients referred to theirpractice from public AOD health services.

We aimed to identify the type and severityof substance use and high-prevalence men-

ealth disorders present in a group ofle seeking treatment at AOD services.xamined the type and prevalence ofent substances and mental health dis-s within the sample, and comparednts with an alcohol-only disorder tonts with a drug or polydrug use dis-

order, using type and severity of anxiety anddepressive disorders. These findings willhelp GPs treat depressive and anxiety symp-toms in substance-dependent clientsreferred to their practice.

METHOD

participants were that they were aged 18years and older; they could speak English;and they had been in treatment no longerthan 4 weeks. People with a psychotic dis-order (as determined by a psychosisscreener) were excluded.9 Participants wereeither referred by case managers or wereself-referred in response to advertising at theAOD service. Case managers identified peo-ple considered to have both mental healthand AOD disorders, and asked permissionto forward their patient details to projectrecruiters. Project recruiters then contactedthe individuals to provide information andinvite participation. This two-step processseparated case managers from active recruit-ment, so individuals did not feel coercedinto taking part. The resulting sample wastherefore nonrandom.

disorders. We show that this group will likely present to their GP with more than one

MJA 2011; 195: S60S63

mental health disorder in addition to acute and chronic physical health conditions.issues invmultiple increasinghealth proThe Medical Journal of Australia ISSN:0025-729X 1 August 2011 195 3 S60-S63The Medical Journal of Australia 2011www.mja.com.auDepression, anxiety and substance use

ecent health service initiativeswithin Australia require alcohol andother drug (AOD) services to iden-

tify and case-manage or treat high-preva-lence mental health disorders such asdepression or anxiety alongside the AODproblems.1,2 Specialist dual-diagnosis work-ers have therefore been funded in Australiato provide primary, secondary and tertiarysupport to AOD services.

The high prevalence of co-occurring men-tal health disorders among clients of AODservices means it is impossible for specialistdual-diagnosis workers to directly treat allclients identified with comorbid mentalhealth disorders. Therefore, they focus theirscarce resources on building capacity inAOD workers to provide integrated treat-ment and providing appropriate externalreferrals for mental health treatments.

General practitioners will increasingly berequired to assist in the treatment of indi-viduals identified by AOD services as havingcomorbid substance and mental health dis-orders, in particular those with depressionand related disorders such as anxiety. This isparticularly likely in the short term, as AODworkers continue to acquire the appropriateskills to manage treatment of dual-diagnosisclients. GPs are able to draw on a range oftreatment approaches for depressive dis-

able treating patients with a single substanceuse disorder, eg, an alcohol use problem,but less familiar with the complexity of

olving polydrug users (users ofdrugs). Yet, as AOD servicesly identify high-prevalence mentalblems such as anxiety or depres-

Identifying depression and anxiety disorders in people presenting for substance use treatment

Petra K Staiger, Anna C Thomas, Lina A Ricciardelli and Marita P McCabe

ABSTRACT

Objective: To identify the type and proportion of depressive and related mental health disorders in a group of individuals seeking outpatient treatment at an alcohol and other drug (AOD) service.Design, setting and participants: A cross-sectional study using diagnostic interviews with 95 participants (56 men, 39 women) seeking treatment from an AOD service.Main outcome measures: Mental health and substance disorders were measured using the Composite International Diagnostic Interview, Posttraumatic Stress Disorder Checklist, Beck Depression Inventory, and StateTrait Anxiety Inventory (Trait Version).Results: This was a complex group with addiction, mental health and physical health conditions; 76% had a depressive disorder and 71% had an anxiety disorder. Most were diagnosed with at least two mental health disorders and 25% were diagnosed with four or more different disorders. Alcohol and cannabis use were the most commonly diagnosed AOD disorders. Further, those diagnosed with a drug use disorder reported significantly higher levels of depression compared with those with an alcohol-only disorder. Finally, 60% of the sample reported chronic health conditions, with over one-third taking medication for a physical condition on a regular basis.Conclusions: Primary care providers such as general practitioners are likely to be increasingly called on to assess, treat and/or coordinate care of patients with AOD

RMJA Volume 195 Number 3 1 August 2011

were not married. The inclusion criteria for and criteria of the Diagnostic and statistical

DEPRESSION, ANXIETY AND SUBSTANCE USEmanual of mental disorders (DSM-IV).11 Weused sections A, D, E, F, J and L of the 12-month version of the CIDI to measuredemographics and assess participants formood and anxiety, and for alcohol andsubstance use disorders. Posttraumatic Stress Disorder Checklist,civilian version (PCL-C):12 we used this self-

reporting scale which assesses symptoms ofpost-traumatic stress disorder (PTSD) basedon DSM-IV diagnostic criteria.11 A cut-offscore of 50 is indicative of a PTSD. Beck Depression Inventory (BDI-II):13 thiswell validated 21-item self-reporting ques-tionnaire was used for assessing the severityof depression. StateTrait Anxiety Inventory (STAI), Traitversion, form Y:14 this was used to measurestable individual differences in proneness toanxiety. Addiction Severity Index, 5th edition:15 wemeasured participants health problems(current and chronic medical problems andmedications prescribed). Demographic data were collected includ-ing age, sex, and age at first drug use.

Percentages, 2 difference tests and multi-variate analysis of variance were used toanalyse the data using SPSS (SPSS Inc, Chi-cago, Ill, USA).

The study was conducted in Melbourne,Australia, and ethics approval for this studywas obtained from Deakin UniversityHuman Research Ethics Committee andSouthern Health Human Research EthicsCommittee.

RESULTS

Substance use problemsRespondents were asked the age at whichthey first used any drug. Results showedthat over 50% of the sample had used a drugof some sort by the age of 14 years. Box 1shows proportions of participants diagnosedwith substance use disorders. Alcohol usedisorder was the most common, reported byover 60% of respondents.

Further examination showed that only 34people (36%) seeking assistance for AODproblems were diagnosed with only onesubstance use problem, alcohol being themost commonly diagnosed single problem(n = 23) (24%). Of the 72 respondents diag-nosed with drug use disorders other thanalcohol misuse, the vast majority (85%)were found to have multiple drug use dis-orders. Twenty-one per cent were diagnosedwith four or more different substance usedisorders.

Health problemsThis group experienced significant healthproblems. Fifty-five respondents (58%)reported that they had a chronic medicalcondition which interfered with their life,while 36 (38%) said they were taking medi-cation on a regular basis for a physicalproblem. Further, 32 (34%) reported expe-riencing medical problems for 15 or moredays over the past month.

Type and severity of high prevalence mental health problemsExamination of the prevalence of mentalhealth disorders in this sample of peopleseeking assistance for AOD disordersshowed that only nine respondents (10%)were not diagnosed with any depressive oranxiety-related disorders, although theyexperienced subclinical symptoms. Nine-teen (20%) were diagnosed with a singledisorder, and 23 (24%) were diagnosed withfour or more different high-prevalence men-tal health disorders. Box 2 shows the pro-portion of people diagnosed with eachdepressive and anxiety-related disorder. Thesample was also split across AOD diagnosesto produce two groups: (i) alcohol use dis-order only; and (ii) drug use disorder (peo-ple in this group may also have beendiagnosed with a concurrent alcohol usedisorder).

As Box 2 shows, 76% of the participantswere diagnosed with a depressive disorder.Those with a drug use disorder (79%)

1 Participants diagnosed with substance use disorder, by substance (n = 95)*

Dependence Abuse Total

Alcohol 60 4 60 (63.2%)

Cannabis 51 10 54 (56.8%)

Sedatives 20 13 32 (33.7%)

Opiates 29 2 31 (33.7%)

Amphetamines 12 0 12 (12.6%)

Hallucinogens 1 2 3 (3.2%)

Cocaine 2 0 2 (2.1%)

Other substances

20 7 27 (28.4%)

* Some participants were in more than one category.

2 Participants diagnosed with depressive and anxiety disorders*

Drug use disorder group (n = 72)

Alcohol use disorder group (n = 23) Total (n = 95)

Depressive disorders

Major depressive disorder

Single episode, mild 10 (13.9%) 4 (17.4%) 14 (14.7%)

Single episode, moderate 4 (5.6%) 6 (26.1%) 10 (10.5%)

Single episode, severe 31 (43.1%) 4 (17.4%) 35 (36.8%)

Recurrent, mild 2 (2.8%) 0 2 (2.1%)

Recurrent, moderate 4 (5.6%) 0 4 (4.2%)

Recurrent, severe 6 (8.3%) 0 6 (6.3%)

Dysthymic disorder 6 (8.3%) 1 (4.3%) 7 (7.4%)

Any depressive disorder 57 (79.2%) 15 (65.2%) 72 (75.8%)

Anxiety disorders

Post-traumatic stress disorder 30 (42.9%) 5 (23.8%) 35 (36.8%)

Social phobia 24 (33.3%) 7 (30.4%) 31 (32.6%)

Generalised anxiety disorder 23 (31.9%) 8 (34.8%) 31 (32.6%)

Obsessivecompulsive disorder 21 (29.2%) 2 (8.7%) 23 (24.2%)

Specific phobia** 8 (11.1%) 4 (17.4%) 12 (13.2%)

Panic disorder 7 (9.7%) 2 (8.7%) 9 (9.5%)

Agoraphobia 2 (2.8%) 1 (4.3%) 3 (3.2%)

Any anxiety-related disorder 52 (72.2%) 15 (65.2%) 67 (70.5%)

* Abuse and dependence disorder statistics were combined to give a single disorder indication for each substance. With or without comorbid alcohol use disorder. Without psychotic features. n = 70. n = 21. ** Animal, natural environment, blood injury or situational phobia. With or without agoraphobia. Without history of panic disorder. MJA Volume 195 Number 3 1 August 2011 S61

appeared more likely to be diagnosed with a

SUPPLEMENTdepressive disorder compared with the alco-hol-only group (65%). However, a 2 testshowed that this difference was not statisti-cally significant (21 = 1.85; P > 0.05). Interms of anxiety disorders, PTSD, general-ised anxiety disorder, social phobia andobsessivecompulsive disorder were themost commonly diagnosed disorders over-all. Those with a drug use disorder weremore likely to be diagnosed with PTSD orobsessivecompulsive disorder but lesslikely to be diagnosed with a specific type ofphobia, compared with those with an alco-hol-only disorder. Follow-up statistical testsshowed that the drug use disorder group(72%) and the alcohol use disorder group(65%) were equally likely to be diagnosedwith an anxiety disorder (21 = 4.11;P > 0.05). Sample sizes were too small insome groups to enable statistical analysis ofgroup differences for the individual depres-sion and anxiety disorders.

The data in Box 2 also suggest that thosewith a drug use disorder suffered from moresevere depressive issues than the alcohol-only group. Multivariate analyses of variancewere conducted to compare severity ofdepression (measured by the BDI) and anxi-ety (measured by the STAI) for the alcohol-only group and those with a drug useproblem. The analysis showed that therewas a significant difference between the twogroups in overall negative affect (Wilkslambda = 0.882; F2, 90 = 6.01; P < 0.01; par-tial 2 = 0.11). Univariate comparisonsshowed that those with a drug use disorderwere significantly higher in severity ofdepression scores (mean = 26.82; SD, 12.14)on the BDI compared with the alcohol-onlygroup (mean = 18.50; SD, 11.74) (F2, 91 =8.01; P < 0.01; partial 2 = 0.08). There wasno significant difference between the drugdisorder group (mean = 55.23; SD, 10.32)and alcohol-only group (mean = 51.00; SD,11.63) on severity of anxiety scores.

We examined whether there were anydifferences between the drug use disordergroup and the alcohol use disorder group interms of chronic and acute health problems.A cross-tabulation with 2 difference testsshowed that the alcohol-only group wereslightly more likely to report chronic medi-cal conditions (61%) than the drug usedisorder group (57%) but this differencewas not significant.

Finally, an analysis-of-variance testshowed no difference in the average numberof days that medical problems were experi-enced over the preceding 30 days for the

13.83) compared with the drug use disordergroup (mean = 10.17; SD, 11.93).

DISCUSSION

Three-quarters of the patients in this grouphad a depressive disorder, and most had atleast two different mental health diagnoses(ie, a depressive and an anxiety disorder)and two or more different substance usediagnoses. Furthermore, around one-quar-ter of the sample had four or more diagnosesin each domain.

These findings emphasise the complexityof issues experienced by many people withAOD disorders, showing that individualswith AOD disorders are not only likely topresent with a depressive disorder,16 butthey are also very likely to suffer from atleast one anxiety disorder.

Therefore, primary care practitioners suchas GPs working with patients with AODdisorders need to consider assessment forboth depressive and anxiety disorders in thispatient group. PTSD, social phobia and gen-eralised anxiety disorder, for example, wereeach identified in more than 30% of cases.The Better Outcomes and Better Access initi-atives are well placed to assist GPs to coordi-nate a comprehensive care plan forindividuals with multiple mental healthdiagnoses.

Treatment may involve a combination ofpsychotropic medication and psychologicalor psychiatric treatment, in line with best-practice recommendations,17 thus poten-tially improving long-term outcomes forthese clients. As these patients were allwithin 4 weeks of treatment for AOD dis-orders, it is likely that anxiety and depres-sion disorders are at least partially due toAOD use and/or withdrawal. However, it isbetter to have an understanding of potentialmental health problems as soon as possible.This allows clinicians to target all disordersin treatment and observe whether anxietyand depression reduce with treatment ofAOD disorders. Targeted treatment can thencontinue when mental health remains aconcern.

Interestingly, our findings highlighted thatthose with a drug use disorder tend to reportmore severe levels of depression than thosewith an alcohol use problem alone, andpossibly a greater likelihood of anxiety dis-orders such as PTSD or obsessivecompul-sive disorder. It is possible that the lifestyleassociated with, and consequences of, illicitdrug use at least partially explains the higher

sample size prohibited statistical compari-sons across groups on individual anxietydisorders, so these findings must be consid-ered with caution until it is confirmed with alarger sample.

The overall physical health of the clientswas poor, with over half reporting chronichealth conditions. Over one-third were cur-rently taking medication on a regular basis,and a similar proportion reported experien-cing medical problems for 15 days or moreover the previous month. The high level ofchronic physical conditions among peoplewho have either a mood or substance usedisorder has been demonstrated in previousstudies,6,18 indicating the importance ofaddressing the primary health care needs ofthese clients.

It is important to note that these findingscannot be generalised to the wider popula-tion of people with AOD disorders, as thestudy specifically targeted people identifiedas potentially having depressive and relateddisorders and excluded those with psychoticdisorders. The sample was therefore nonran-dom. Patients initially presenting to GPs orprimary care with AOD problems, for exam-ple, may differ from the patients we studied.This approach was adopted because thefocus of our study was on AOD treatment-seekers with high-prevalence mental healthdisorders, as these individuals are likely tobe excluded from public specialised mentalhealth services (ie, where treatment isfocused on low-prevalence mental healthdisorders).

Recent policy initiatives have led toincreased identification of high-prevalencemental health disorders within AOD serv-ices. This suggests that GPs will increasinglybe called on to assess, treat and/or coordi-nate care of this patient group. Our findingsemphasise that this group will generallypresent to their GP with more than onemental health disorder, along with acute andchronic physical health conditions. In themedium-to-long term, AOD services willneed to ensure their workers obtain thenecessary skills to manage and treat high-prevalence mental health problems in-house, which may require improvedresourcing of such services.

ACKNOWLEDGEMENTSThis study was assisted by a beyondblue VictorianCentre of Excellence in Depression, Anxiety andRelated Disorders grant. We thank staff at South-ern Health, the interviewers, Wendy Cross, GregYoung, the participants, Rob Campbell and AmeliaS62 MJA Volume 195 Number 3 1 August 2011

alcohol-only group (mean = 12.70; SD, severity of depression in this group. The Lake for their assistance with data collection.

DEPRESSION, ANXIETY AND SUBSTANCE USECOMPETING INTERESTSNone relevant to this article declared (ICMJE dis-closure forms completed).

AUTHOR DETAILSPetra K Staiger, PhD, Associate ProfessorAnna C Thomas, PhD, Research FellowLina A Ricciardelli, PhD, Associate ProfessorMarita P McCabe, PhD, ProfessorSchool of Psychology, Deakin University, Melbourne, VIC.Correspondence: pstaiger@deakin.edu.au

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(Received 20 Aug 2010, accepted 13 Apr 2011) MJA Volume 195 Number 3 1 August 2011 S63

METHODRESULTSDISCUSSIONAcknowledgementsCompeting interestsAuthor detailsREFERENCES