Search

In collaboration with the National Institute on Drug Abuse, the Health Resources and Services Administration is conducting a multisite, longitudinal study on issues of service needs, service utilization, and access to care for drug abusers with HIV. This article discusses access to drug abuse treatment and HIV secondary prevention for 116 women interviewed during the study's first year in five U.S. cities. Using interview data from 115 service providers in those same cities, it also discusses drug abuse treatment availability and barriers to service expansion for drug users with HIV. Study findings indicate that there are highly significant gaps between the drug abuse treatment services these women feel they need and those they have been able to receive; these were particularly pronounced for drug detoxification and residential and outpatient drug-free treatment. Women who used crack cocaine or injection drugs had particularly high levels of need for residential and outpatient drug abuse treatment, while women who use crack were found to have significantly less experience with the drug abuse treatment system than IDUs. HIV secondary prevention was also found to be a critical need for these women, many of whom were engaging in behaviors that place them at risk for reinfection, infection with other diseases, and transmission to others. Providers indicated that lack of funding was the major barrier to expanding services for this population; other barriers, such as lack of ancillary services and transportation, were also noted. Two positive findings were that many drug abuse treatment agencies in these cities provide a wide range of ancillary services and that many different kinds of agencies offer drug abuse treatment services.

The authors investigated the association between "heavy drinking" and sexual behaviors among 2,581 general population subjects from the St. Louis Epidemiologic Catchment Area survey conducted from 1981 to 1983. Lifetime sexual behaviors included promiscuity, infidelity, receiving money for sex, and same gender sex. It was found that sexual behaviors were associated with lifetime heavy drinking. Regardless of gender, race, or age, "heavy drinkers" were significantly more likely to report each of the high risk sexual behaviors, except same gender sex, compared to "nonheavy drinkers." With the multiple logistic regression analyses it was found that "heavy drinking" non-Black females, Black males regardless of drinking history, "heavy drinking" males, and younger subjects regardless of drinking history were at higher risk to report the high risk sexual behaviors. This study confirms that there is a strong association between "heavy drinking" and high risk sexual behaviors in a midwestern population. This is the first study to find an association between alcohol drinking patterns and high risk sexual behaviors in the general population. Implications of these findings for public health education efforts are discussed.

The present study assesses the stability of the diagnosis of alcoholism among a sample of St Louis, USA Epidemiological Catchment Area Study participants. The Diagnostic Interview Schedule was used at Time 1 and the Composite International Diagnostic Interview--Substance Abuse Module was used at 10-year follow-up. Alcohol abuse and dependence were diagnosed using DSM-III criteria. Kappa values and Yule's statistics for agreement in diagnoses, criterion groups and individual symptoms are reported. Fair to good measurement of agreement was shown for any diagnosis of alcohol abuse or dependence versus no diagnosis. The criterion group for "impairment in social or occupational functioning" showed the highest agreement of the three criterion groups studied. Agreement was lower for individual symptoms of alcoholism. Incident cases accounted for some of the inconsistency in responses over 10 years. Other types of inconsistency found were changing response from yes to no, changing response from no to yes but not meeting the definition of an incident case, and misstating age of onset of symptoms. Mean per cent inconsistency across all symptoms was 11.4%. Further research regarding reasons for inconsistencies is needed.

This paper presents first-year findings from a multi-site, longitudinal study being coordinated by the Health Resources and Services Administration (HRSA) in collaboration with the National Institute on Drug Abuse (NIDA) on access to care for drug abusers with HIV. The sample of 116 women and 187 men in five sites (Denver, Detroit, New Haven, New Orleans, and St. Louis) were interviewed regarding HIV testing history, HIV disease course, and use of health and social services. For both men and women, there were significant gaps between the medical services they reported needing and those they received. Significantly more women needed and received mental health services. Cost and waiting times emerged as the most important barriers to care. The study also found that significantly fewer women than men subjects received pre- and post-test counseling and were advised to get medical services after their first positive HIV test. Overall, first-year study results suggest that multiple barriers in access to service exist for drug-using women, the largest group of women affected by HIV in the United States.

A computerized version of the Diagnostic Interview for Children and Adolescents-Revised (DICA-R) has been developed. There are three versions of the interview, one for children aged 6 to 12, one for adolescents aged 13 to 18, and one for parents of children aged 6 to 18. Acceptability and reliability studies of the child and adolescent versions were performed on 93 subjects. The results show that children of all ages enjoyed the computer, and most were able to complete the interview with very little help. Reasonable reliability was found for both age groups despite difficulty with certain diagnostic criteria.

The concept of a dependence syndrome with graded levels of severity was originally derived from work with alcoholics. The applicability and clinical utility of the dependence syndrome across a wider range of substances was examined as part of the DSM-IV field trials. When using a criterion count method to assess severity, it was found that persons cluster at different severity levels according to the drug on which they are dependent. Across all drug classes, severity correlated reasonably well with measures of quantity and frequency of use and with associated problems. The relationship between severity ratings and outcome was not tested, however data from other studies indicate that severity is only one of many factors that can influence outcome.

At the present, the DSM-III-R is nearing the final stages of metamorphosis to DSM-IV. A series of field trials has been completed which has focused the attention on coverage of the different systems, the impact of social and legal problems on crossing the diagnostic threshold, the importance of subtyping by tolerance and withdrawal, the exclusionary diagnosis of abuse, the duration criterion, and other nosological comparisons. The focus of this Data Note is the comparison of rates between DSM-III, III-R, and both the old and new ICD-10 diagnostic systems, using data from the DSM-IV Substance Use Disorders Field Trials. Especially noteworthy is the inclusion of African Americans, females, and a population with a range of diagnoses and use patterns. Comparisons of DSM-III, III-R and ICD-10 substance use diagnoses among alcohol, nicotine, cannabis, cocaine substance users indicate considerable agreement for dependence but less similarities between systems for abuse and harmful use. These findings suggest that the dependence criteria may be more stable than those chosen to represent abuse and harmful use. More work needs to be done to evaluate the differences and similarities of the diagnostic systems.

More health care facilities are involved in the delivery of substance abuse treatment today than ever before. A program or health care facility administrator needs to be well informed before attempting to establish a treatment program. A knowledge of both the illness and the available treatment options is necessary to evaluate effectively the fiscal and community benefits of providing alcohol and chemical abuse and dependence treatment. The most successful long-term benefits are seen when community services are coordinated and persons seeking treatment are referred to the treatment program that best suits their individual needs. Education--of both hospital personnel and the community--is the foundation of any treatment program. Prevention and early intervention are the cornerstones of treatment. A broad view of the problems related to substance abuse will aid the administrator in a careful assessment of the needs of the community. Only then can the administrator benefit the institution and the entire community.

Objective: The purpose of the study was to evaluate the prevalence of posttraumatic stress disorder (PTSD) among substance users in the general population., Method: The St. Louis Epidemiologic Catchment Area study, a survey of psychiatric illness in the general population, collected data on PTSD and substance use with the Diagnostic Interview Schedule. Among the 2,663 respondents, 430 reported a traumatic event that could qualify for PTSD; however, the rate of PTSD was low, 1.35% overall. To evaluate the relationship between PTSD and substance use, respondents were hierarchically classified into one of four substance use categories ranging from polydrug use to alcohol use only. Substance users from each category as well as substance users in general were compared with persons who did not meet the substance use threshold (comparison subjects)., Results: Findings indicate that cocaine/opiate users are over three times as likely as comparison subjects to report a traumatic event, report more symptoms and events, and are more likely to meet diagnostic criteria for PTSD. Physical attack, but not combat-related events, was the most prevalent event reported among cocaine/opiate users. Onset of substance use preceded onset of posttraumatic symptoms, suggesting that substance use predisposes the individual to exposure to traumatic events. When other variables--including antisocial behavior--were controlled, female gender and use of cocaine/opiates predicted PTSD., Conclusions: These analyses of the co-occurrence of substance abuse and PTSD warrant further study and suggest that PTSD is much more common among substance abusers than was previously known.

The CIDI is a fully standardised, structured interview for the assessment of psychiatric disorders according to DSM-III-R and proposed ICD-10 criteria. The development of this interview has been the collaborative effort of researchers from 18 sites around the world. In a field trial to test the cross-cultural acceptability and reliability of the questions, there was found to be high acceptance and excellent reliability for the substance use questions, problems with the lengthy alcohol section, and difficulties translating relevant substance use concepts into different languages. There is therefore room for further improvement in the substance-related questions. There proved to be differences between ICD-10 and DSM-III-R regarding substance abuse and dependence disorders.

The CIDI is a fully standardised diagnostic interview designed for assessing mental disorders based on the definitions and criteria of ICD-10 and DSM-III-R. Field trials with the CIDI have been conducted in 18 centres around the world, to test the feasibility and reliability of the CIDI in different cultures and settings, as well as to test the inter-rater agreement for the different types of questions used. Of 590 subjects interviewed across all sites and rated by an interviewer and observer, 575 were eligible for analysis. The CIDI was judged to be acceptable for most subjects and was appropriate for use in different kinds of settings. Many subjects fulfilled criteria for more than one diagnosis (lifetime and six-month). The most frequent lifetime disorders were generalised anxiety, major depression, tobacco use disorders, and agoraphobia. Percentage agreements for all diagnoses were above 90% and the kappa values were all highly significant. No significant numbers of diagnostic disconcordances were found with lifetime, six-month, and four-week time frames.

There is growing concern worldwide about the extent of psychoactive substance abuse and dependence disorders. Epidemiological data are needed to assess the prevalence and severity of the problem. Collecting this type of data is possible with a highly structured and reliable diagnostic interview. The problems involved in developing such an interview are discussed in this chapter. They include the absence of a unified concept of psychoactive substance dependence and a lack of a standardized system of diagnostic criteria. Recently a new instrument has been designed to assess psychoactive substance abuse and dependence disorders according to multiple diagnostic systems. The WHO/ADAMHA Composite International Diagnostic Interview Substance Abuse Module (CIDI-SAM) has been found to have excellent diagnostic reliability in a test-retest pilot study. This chapter describes the development and evolution of the interview and offers guidelines for operationalization of substance abuse and dependence criteria.

Utilization of health and mental health services by non-institutionalized persons aged 18 years and older is examined based on interviews with probability samples of 3,000 to 3,500 persons in each of three sites of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) program: New Haven, Conn, Baltimore, and St Louis. In all three ECAs, 6% to 7% of the adults made a visit during the prior six months for mental health reasons; proportions were considerably higher among persons with recent DSM-III disorders covered by the Diagnostic Interview Schedule (DIS) or severe cognitive impairment. Between 24% and 38% of all ambulatory visits by persons with DIS disorders were to mental health specialists. In seeking mental health services, men were more likely to turn to the specialty sector than to the generalist; women used both sectors about equally. The aged infrequently received care from mental health specialists. Visits for mental health reasons varied considerably depending on specific types of DIS disorder.

The CIDI-SAM is a fully-structured interview that ascertains DSM-III, DSM-III-R, Feighner, RDC and ICD-10 diagnoses for alcohol, tobacco and nine classes of psychoactive drugs. It was designed at the request of the WHO/ADAMHA Task Force on Psychiatric Assessment instruments to expand the substance abuse sections of the CIDI. Using a test-retest design, the diagnostic and item reliabilities of this instrument were tested in a sample of 39 patients in substance abuse treatment at three St. Louis treatment facilities. Kappa values and their 95% confidence intervals, and Yule's Y values are reported. The average kappa for DSM-III substance disorders was 0.84, for DSM-III-R it was 0.82. We report, on the average, excellent kappa values for individual alcohol and drug symptoms. We also ascertained from the respondent's themselves the reasons why answers to specific questions might have been discordant. The findings from this unique 'discrepancy interview' are reported.