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Though remission of substance-use disorders (SUDs) has been correlated with increased odds of smoking cessation, a subgroup of remitters continues to smoke. However, information regarding this population is lacking. Data from the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed. The sample included 1417 smokers with SUDs who completed Wave 1 (Baseline) and Wave 2 (Follow-up) assessments. Results indicated that the presence of generalized anxiety disorder, Cluster A personality disorders, major depression/dysthymic disorder, or manic depression/hypomanic disorder since Wave 1 was associated with a reduced likelihood of smoking cessation. These data suggest that healthcare providers who treat smokers in remission from SUDs should carefully assess for the presence of mood disorders and provide appropriate treatment, as well as offering adjunctive evidence-based smoking cessation treatments.

Purpose The aims of this study were to identify predictors of remission from chronic depression in a prospective longitudinal general population survey; second, to determine the relative level functioning and well-being of those in remission. Methods The sample included respondents who met the criteria for major depressive disorder from Wave 1 (2001–2002) and through Wave 2 (2004–2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Results Panic Disorder, Generalized Anxiety Disorder, Cluster B personality disorders and a history of Physical Abuse were correlated with reduced likelihood of chronic depression remission. The functioning and well-being of the remitted group was below the norm. Conclusions These prognostic factors are similar to those found in clinical samples. Despite remission from chronic depression, a significant proportion have impairments in functioning.

Aim To evaluate whether venlafaxine-extended release (VEN-XR) is an effective treatment for cannabis dependence with concurrent depressive disorders.

Background: During the past decade, several novel medication treatments and psychosocial interventions have been tested. Overall, their impact on reducing alcohol use and preventing relapse has been modest. These outcomes have spurred researchers to investigate whether the addition of manualized psychosocial therapies with demonstrated efficacy to pharmacotherpy would have a synergistic effect. Objectives: We conducted a meta-analysis to test the hypothesis that the addition of manualized psychosocial therapies would reduce the frequency of relapse. Results: This review analyzed data from six studies. Among studies that used random assignment to manually guided psychosocial interventions, the rates of relapse between the naltrexone plus a psychosocial intervention and naltrexone without a psychosocial intervention were very similar. Among patients allocated to placebo, similar rates of relapse were also found between Cognitive Behavioral Therapy (CBT) and non-CBT. In studies which used manualized psychotherapies as a platform, relapse rates were similar between naltrexone and placebo. In contrast, studies using Treatment As Usual psychotherapy as a platform demonstrated lower rates of relapse in the naltrexone group, compared to placebo group. Conclusions: We conclude that CBT does not appear to offer benefits beyond those derived from study medications. Scientific Significance: The benefit of the addition of CBT to medication in preventing relapse may be limited. (Am J Addict 2012;21:501–507)

This study hypothesized that the well-being of community residents in remission from major depression disorder (MDD) would not be significantly different from those without MDD. Data from the Midlife in the United States Survey (MIDUS), a prospective general population survey conducted in 1995 and 2004, were analysed. A comparison of the psychological well-being scores, Big Five personality scores and life satisfaction scores of remitted and non-remitted respondents revealed generally small effect size differences. The remitted group were more likely than the non-remitted group to have had past-year panic disorder at follow-up. In general, these results suggest that the well-being of respondents in MDD remission was relatively high.

To determine if Attention Deficit Hyperactivity Disorder (ADHD) is a risk factor for suicide attempts.Data were drawn from the National Comorbidity Replication Survey (NCS-R), a nationally representative sample of adults (N=8098).Of the 365 adults with current ADHD, 16% attempted suicide. After controlling for the presence of comorbid disorders, logistic regression analyses revealed that the ADHD was not a not a strong predictor of suicide attempts; having one or more comorbid disorders was associated with fourfold to twelvefold elevated risk.The small sample size of respondents with ADHD who attempted suicide significantly reduced the probability of determining which specific comorbid disorders were correlated with parasuicide.Early treatment of ADHD and comorbidity may reduce the risk of suicide attempts and improve its prognosis.

Background Chronic depression is associated with impaired functioning. The National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) is a representative sample ( N = 43,093) of the United States non-institutionalized population aged 18 years and older. We hypothesized that individuals with chronic low-grade depression, dysthymic disorder, would have more impaired functioning than individuals with acute major depression or the general population. Method Diagnoses were generated by the NIAAA Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). The dysthymic disorder (DD) sample ( N = 328) consisted of DD diagnosis without current MDD. The dysthymic group was not chosen on the basis of alcohol use or abuse. Individuals with MDD with duration ≦24 months, without lifetime DD constituted the acute depression (AD) sample ( N = 712). All other respondents were classified as general population (GP) ( N = 42,052). Past year functioning was assessed by Supplemental Social Security Income (SSI), employment, and Medicaid statuses. Past month functioning was assessed by Short-form 12-Item Health Survey (SF-12), with scores for social functioning, role emotional functioning, and mental health, using odds ratios. Results Over the past year, compared to AD, persons with DD were less likely to work full-time (36.2% vs. 44%; OR = 0.70, CI = .54,.92) and more often received SSI (13.9% vs. 4.5%; OR = 3.4, CI = 2.0,5.9) and Medicaid (20.2% vs. 13%; OR = 1.7 , CI = 1.1,2.6). Dysthymics reported accomplishing less over the past month due to emotional problems, and that emotional or physical problems interfered with social activities. Relative to GP, respondents with DD were more likely to receive SSI (13.9% vs. 2.9%; OR = 4.6, CI 3.4,6.2) and Medicaid (20.2% vs. 5.9%; OR = 2.9, CI 2.0,4.1). Compared to GP, dysthymics reported accomplishing less due to emotional problems, and that emotional or physical problems interfered with social activities and work functioning. Conclusions DD-associated psychosocial impairment in the community setting comprises a significant public health burden.

Background The impact of personality disorders (PD) on the course of depression has been gaining interest among clinical researchers over the past decade. Recent observational studies have found that PD was associated with impaired social functioning and reduced likelihood of depression recovery. Elevated rates of PD have been noted in early-onset and chronic forms subtypes of depression. However, scant data exist regarding the link between PD and outcome for this depression subtype. Methods The National Epidemiological Survey on Alcohol and Related Conditions database was analyzed. This survey included 43 093 respondents, 18 years and older, conducted in 2001 through 2002. Logistic regression was used to identify demographic and clinical predictors of remission in early-onset chronic depression. Results The absence of PD, having more years of education, and being married considerably improved the likelihood of remission. Paranoid personality disorder and obsessive-compulsive disorder were the only specific PD found to be associated with a reduced probability of remission. Limitations Depression remission status may have biased the recollection of PD symptoms. Borderline personality disorder, narcissistic personality disorder, and schizotypal personality disorder were not assessed. Conclusions This study suggests that PD are significant predictors of remission in early-onset chronic depression.

This article tests the hypothesis that remission from substance use disorders is associated with smoking cessation in nicotine dependent young adults.The sample was composed of 976 young adults with lifetime substance use disorders and nicotine dependence who were subjects in the national epidemiologic survey on alcohol abuse and related conditions (NESARC). The Associated Disabilities Interview Schedule-DSM-IV Version was used to assess lifetime and past year psychiatric disorders.Past year nicotine cessation was obtained by self-report. Remission from substance use disorders was defined as the past year absence of DSM-IV substance use disorders. This study found that remission from substance use disorders increased the likelihood of smoking abstinence (OR=1.7).Our study found that remission from substance use disorders increased the likelihood of smoking abstinence in early adulthood. This finding is congruent with results from longitudinal studies.

Objective To compare rates of comorbidity, treatment utilization, the course of illness, and past year social functioning of Hypomania with and without Dysphoria Hypomania (mixed state). Method The National Epidemiological Survey on Alcohol and Related Conditions (NESARC) was a nationally representative face-to-face survey of 43,093 respondents, aged 18 years and older, conducted in 2001 through 2002. The target population of the survey is the civilian, noninstitutionalized population residing in the United States. Results Dysphoric Hypomania was associated with an increased lifetime risk for major depression, dysthymic disorder, anxiety disorders and personality disorders compared to Non-Dysphoric Hypomania. The former group had an earlier onset age of major depression, more episodes major depression and hypomania, and had a higher rate of treatment contact than the later group. Past year personal income and the frequency of full-time employment were lower in the Dysphoric Hypomania compared to Non-Dysphoric Hypomania. Conclusions Dysphoric Hypomania is a more severe and persistent mood disorder compared to Non-Dysphoric Hypomania.

Cannabis Dependence remains a highly prevalent disorder in the United States. Though longitudinal studies have accumulated data regarding risk factors and psychosocial correlates of habitual cannabis use, the field lacks knowledge regarding predictors of recovery in community samples. Thus we conducted a secondary data analysis of The National Epidemiological Survey on Alcohol and Related Conditions to address this issue. Recovery was defined as the absence of Cannabis Dependence and Cannabis Abuse during the past year. Logistic Regression analysis revealed that older age, marriage, and non-daily cannabis use were positively associated with recovery.

Background: Atypical depression is associated with elevated rates of personality disorders. Studies have confirmed the efficacy of a several antidepressants in the treatment of atypical depression. Whether their pathological dimensions of personality diminish after benefitting from effective medication treatment is unclear. Aims: To determine the extent that pathological dimensions of character improved among patients who benefitted from treatment. Method: One-hundred and fifty-four outpatients with DSM-IV Major Depression who met Columbia criteria for atypical depression were randomized to receive fluoxetine, imipramine or placebo for a 10-week double-blind clinical trial. The Temperament and Character Inventory (TCI) was administered at the initiation of treatment and 8 weeks later. Low scores on either of two Character dimensions (Self-Directiveness or Cooperativeness) indicate psychopathology. Results: Responders had a substantial reduction in Harm Avoidance, but post-treatment scores remained significantly higher than the normal control group (NCG). Fluoxetine and Imipramine did not produce different changes on personality, except for Self-Transcendence. Limitations: High proportion of missing data, inadequate sample size, post-hoc analysis. Conclusions: Among responders, Self-Directiveness improved and normalized; Harm Avoidance also improved but did not normalize. These data suggests that effective treatments reduce some pathological personality traits as well as improving mood.

Cannabis is the most widely used illegal drug in the U.S. population. Surveys have estimated that the lifetime prevalence rate for cannabis dependence is approximately 4%. Though the presence of a psychiatric disorder increases the likelihood of developing substance dependence, the field lacks data regarding the association between mental disorders and cannabis dependence. The aim of this study is to describe the prevalence of psychiatric disorders among individuals with cannabis dependence. The National Comorbidity Survey was used to obtain these data. We found that 90% of respondents with cannabis dependence had a lifetime mental disorder, compared to 55% without cannabis dependence. Alcohol dependence, antisocial personality disorder, and conduct disorder had the strongest associations with cannabis dependence, followed by anxiety and mood disorders. A large proportion of respondents with internalizing disorders developed mood or anxiety disorders prior to onset of their first cannabis dependence symptom. Data regarding the prevalence of comorbid mental disorders underscore the importance of thorough and systematic evaluation of patients seeking treatment for cannabis dependence. The failure to identify comorbidity may lead to inadequate treatment, and a poorer prognosis.

Background: Though the social functioning of most depressed outpatients improves with effective treatment, a subgroup may remain impaired after recovering from depression. The purpose of this study was to identify predictors of residual social impairment among patients who recovered from depression. Methods: These data were obtained from the Treatment of Depression Collaborative Research Program (TDCPR) public access tape. The TDCPR tested the relative efficacy of two psychotehrapies, imipramine, and placebo in major depression. Patients received follow-up assessments after completing the clinical trial. The following assessment instruments were used to assess predictor variables: Social Adjustment Scale II, Personality Assessment Form (PAF), Longitudinal Interval Follow-up Events (LIFE), and the Schedule for Affective Disorders (SADS). Results: Recovered patients who were socially impaired at the end of treatment and six months later, had a higher rate of Intermittent Depression, and reported greater malfunctioning during adolescence than recovered patients whose functioning was unimpaired after treatment and at follow-up. The rates of personality disorders were not significantly different between these groups. Limitations: These analyses were performed post-hoc and the sample size was small. Conclusions: A chronic course of depression predicted persistent social maladjustment among patients who recovered from depression for 6 months.

BackgroundIn spite of the virtually ubiquitous nature of the initial 10-day placebo run-in period (IPR) in drug trials, there is little empirical data establishing its relevance.MethodData from 593 subjects were examined retrospectively to determine whether or not the prognosis of subjects minimally improved during the IPR was different to those who were unimproved. The IPR period was single-blind and was followed by a six-week double-blind phase in all studies.ResultsTwenty-six per cent of the subjects were minimally improved and 74% were unimproved. Approximately 10% of the subjects who were much improved were not followed systematically. Across a range of diagnosis, severity and chronicity subjects minimally improved (versus unimproved) after IPR had a more favourable prognosis whether assigned to drug or placebo.ConclusionsChange during IPR appears to be a meaningful predictor. Stratification should be considered in future antidepressant studies.

The authors compared the effectiveness of Cognitive Behavioral Therapy (CBT), Interpersonal Psychotherapy (IPT), Imipramine Clinical Management (ICM) to Placebo Clinical Management (PCM) for outpatients with early-onset chronic depression (N = 65) in the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDRP). The post-treatment depression scores of the CBT. IPT, and ICM groups were not significantly different from the PCM group. We did not find a relationship between the duration of Major Depression and response to a specific treatment. Studies are needed to determine if combining psychotherapy with medication improves social functioning and enhances the quality of life for patients with chronic depression.

This study sought to determine clinical predictors of alcohol relapse during recurrence of major depression. The total sample included 2,820 adults with a history of alcohol dependence who had a comorbid current episode of major depression. Twenty-six percent had a relapse of alcohol dependence. Relapsers were more likely to be male, single, less educated, and younger than non-relapsers. Early onset alcohol dependence and past year drug use disorder significantly increased the likelihood of relapse. Early onset substance use dependence is a more powerful predictor of alcohol relapse than early onset major depression.

Background This study sought to characterize the morbidity and treatment behavior of 49 patients with early-onset chronic depression, 6 months after terminating treatment at a university-based psychopharmacology research clinic. Method Patients with and without early-onset chronic depression were selected to participate in a naturalistic follow-up study. Assessments were conducted blind to patients' histories. Patients' depressive symptoms, psychosocial functioning, and post-discharge treatment histories were assessed. Results After termination, the mean length of recovery for the sample was 3.6 months. When they left the clinic, 78% (38/49) were euthymic. At follow-up, 37% (14/38) of these had relapsed; while 45% (17/38) remained in remission for 6 months. During the follow-up period, 47% of the patients were on antidepressants. Sixty-three percent of the patients who relapsed, or were depressed when they left the clinic, did not enter treatment, 50% of whom cited insufficient resources as the primary reason for not receiving care. Conclusions After leaving a depression research clinic, a substantial portion of patients with early-onset chronic depression remained recovered during a 6-month period, but financial impediments prevented a majority of those who did poorly from entering treatment. Depression 4:63–67 (1996). © 1997 Wiley-Liss, Inc.

Meta-analysis was used to assess the relative efficacy of various treatments in reducing alcohol consumption over the short-term, 6 months, and 12 months. All the treatments were administered in well-controlled studies. In the short-term and 1-year follow-up studies, patients in the experimental group drank much less than the control group. However, between group consumption differences were negligible in the 6-month studies. When the studies were pooled, regardless of the follow-up assessment periods, the experimental group drank significantly less than the control group. These results suggest that, in general, patients who received experimental treatments consumed much less alcohol than patients in the control groups.

During the past decade, several novel medication treatments and psychosocial interventions have been tested. Overall, their impact on reducing alcohol use and preventing relapse has been modest. These outcomes have spurred researchers to investigate whether the addition of manualized psychosocial therapies with demonstrated efficacy to pharmacotherpy would have a synergistic effect. We conducted a meta-analysis to test the hypothesis that the addition of manualized psychosocial therapies would reduce the frequency of relapse. This review analyzed data from six studies. Among studies that used random assignment to manually guided psychosocial interventions, the rates of relapse between the naltrexone plus a psychosocial intervention and naltrexone without a psychosocial intervention were very similar. Among patients allocated to placebo, similar rates of relapse were also found between Cognitive Behavioral Therapy (CBT) and non-CBT. In studies which used manualized psychotherapies as a platform, relapse rates were similar between naltrexone and placebo. In contrast, studies using Treatment As Usual psychotherapy as a platform demonstrated lower rates of relapse in the naltrexone group, compared to placebo group. We conclude that CBT does not appear to offer benefits beyond those derived from study medications. The benefit of the addition of CBT to medication in preventing relapse may be limited.

Meta-analysis was used to establish the efficacy of various controlled alcohol misuse treatments in maintaining abstinence over short-term, 6-month, and 12-month follow-ups. Effect sizes were measured by odds ratio. Aggregate effect size differences between experimental and control groups were negligible. Only three of 15 studies found a clinically significant difference between treatment abstinence outcomes.

Social functioning was evaluated in 61 chronically depressed adults with early onset. Patients were treated for 6 weeks in a double-blind trial of phenelzine, imipramine, L-deprenyl, or placebo and functioning was reassessed. The posttreatment social functioning of patients who received drug treatment was superior to the placebo group in the following areas: work functioning, house functioning, relationship with relatives, sex frequency and life satisfaction. These results suggest that psychosocial impairment in some chronic depressives may be a sequaela of depression, rather than a global manifestation of characterological pathology.

Sparse data exist regarding the risks and benefits of treating bipolar-II depression with antidepressants alone. On the basis of studies of bipolar-I patients, treatment guidelines suggest antidepressants should be augmented with mood stabilizers. Whether these recommendations apply to bipolar-II is unclear. A post-hoc analysis of a double-blind study, which compared the relative efficacy of placebo, imipramine and phenelzine in depressed outpatients. Patients rated 1 ('very much improved') or 2 ('much improved') on the Clinical Global Inventory Scale were considered responders. In an intent to treat analysis, no significant differences between bipolar patients (N=62) and unipolar patients (N=248) in response rates to placebo, imipramine and phenelzine were seen. No patient developed manic symptoms that required medication discontinuation or mood stabilizer augmentation. Antidepressant monotherapy was found to be a safe and effective treatment for bipolar-II depression.

A large proportion of patients treated for substance dependencies have attempted suicide. Scarce empirical evidence exists regarding their prognosis. Data from the Drug Abuse Treatment Outcome Survey were analyzed to determine the course of depression and substance dependence of 416 suicide attempters one year after discharge. The likelihood of recovery from drug dependence did not differ between patients who did or did not attempt suicide. Among suicide attempters who recovered from substance dependence, the frequency of Major Depression Disorder was significantly lower compared to admission, but its prevalence was nearly three times higher than that found in the general community.

There is a paucity of epidemiological data regarding the effects of substance use dependence (SUD) on the course of depression. This study analyzed data from the National Comorbidity Survey (NCS). Among respondents with lifetime SUD and unipolar depression, current SUD increased the risk (OR = 2.9) of past year depression and anxiety disorders (OR = 2.2).

Epidemiological studies have repeatedly shown that cannabis is the most commonly used illegal drug in the United States. Furthermore, individuals with cannabis dependence have high rates of comorbid substance use disorders and depression. A significant proportion of individuals with addictive disorders develop withdrawal symptoms, cannot control their drug use despite substantial adverse psychosocial consequences, and frequently have a coexisting psychiatric disorder. Nevertheless, only a minority of persons with cannabis dependence ever seek treatment. We were unable to locate epidemiological reports regarding treatment seeking behavior among persons with cannabis dependence. Epidemiological studies of populations with substance disorders have observed that employment, higher educational level, previous use of treatment, major depression, and a co-occurring substance dependency increased the probability of seeking treatment for alcohol dependence. Thus we hypothesized that the same variables would predict service use among persons with cannabis dependence. The main findings of this study were that persons with cannabis dependence were more likely to contact a professional during the past year if they previously sought treatment and had alcohol dependence with major depression. Prospective, longitudinal studies of adolescents would increase our understanding of the processes by which individuals identify themselves as having problems related to their habitual use of marijuana, and why some seek help while others do not.

Medication discontinuation due to intolerable side-effects remains a significant clinical problem in the treatment of depression. We were unable to locate studies which found predictors of medication cessation due to side-effects. We posited that an identifiable subgroup of medically healthy, depressed adults who discontinued medication because of adverse events would have higher pre-treatment somatic symptoms than patients who completed a course of treatment. The sample (n =940) was drawn from a series of double-blind, placebo-controlled studies of antidepressants (imipramine, phenelelzine, L-deprenyl, mianserin and desipramine). Within the medication group, side-effect dropouts had more somatic symptoms than study completers and those who discontinued treatment for miscellaneous reasons. Within the placebo-treated group, the small number of subject who discontinued treated because of side-effects precluded valid statistical analyses, but the findings were in the same direction as those in the medication group. Clearly, further research is required to determine whether these results, obtained from a series of university-based clinical trials with healthy subjects, are generalizable to patients with significant comorbid medical and/or psychiatric disorders, treated with newer antidepressants agents in a general clinical practice setting.

Background: There are scant data regarding the demographic and psychosocial characteristics of outpatients with Atypical Depression (AD). Methods: The demographic characteristics, rates of chronic dysphoria, baseline Symptom Check List Revised, and Social Adjustment Scale scores of 320 moderately depressed patients with and without AD were compared. Results: ADs had a higher number of self-reported symptoms, greater impairments in functioning, and higher rates of chronic dysphoria and bipolar II than patients without Atypical Depression (NAD). Limitations: Variables used in this study were mostly cross-sectional, and the analyses were performed post-hoc. Conclusions: These data suggest ADs had a more pernicious course of illness than NADs, and that patients with AD were more symptomatic and dysfunctional at admission.

Background: Results from short-term treatment studies have demonstrated the efficacy of antidepressant medications for outpatients with early-onset chronic depression. However, scant data exists regarding the long-term outcome of these patients treated for this disorder. Methods: The author conducted a one-year naturalistic follow-up study of 50 outpatients with early-onset, chronic depression, who were treated in a university-based psychopharmacology research clinic. Assessments were conducted blind to the patients' histories. Results: Forty-eight percent of the total sample reported 9–12 months of sustained euthymia (Months Well). Among the patients who recovered, 50% relapsed. Limitations: The major limitations of this study were its small sample size and lack of a comparison group. Conclusions: These results data demonstrate that despite initial response, many outpatients with chronic depression seem to relapse after leaving university-based psychopharmacology centers.

Background: Scant data exists regarding the global mental health of recovered chronically depressed outpatients. The purpose of this study was to compare the symptoms and functioning of these patients to those found in a normal control group (NCG). Methods: Social functioning was assessed by the Social Adjustment Scale interview. Symptoms were measured with the Symptom Check List-90. Results: The overall social functioning of recovered females was more impaired than a NCG. Recovered males and females had more psychiatric symptoms than a NCG. Limitations: The two samples were not demographically similar. Conclusions: Though the differences in social functioning and symptoms between the recovered patients and NCG's were statistically significant, they were not clinically meaningful. In general, recovered females had a relatively robust level of mental health.

It is unclear whether depressed patients who respond to treatment, and subsequently recover, manifest a significant degree of residual symptomatology and enduring psychosocial impairment. The purpose of this study was to compare the social functioning and symptoms of depressed outpatients who responded to acute treatment, and had a sustained recovery from major depression for 6 months, with psychiatrically normal community samples. The sample (n = 48) was drawn from the NIMH Treatment of Depression Collaborative Research Program. The Social Adjustment Scale scores and the Symptom Check List of recovered patients were clinically indistinguishable from the community sample scores. These data suggest that patients who benefit from acute treatment and recover from major depression can expect to achieve a normal level of functioning and symptomatology.

Background: Depressive disorders are commonly comorbid with alcoholism, particularly in treatmentseeking samples. If antidepressant treatment were safe and improved the treatment outcome in the subset of actively drinking alcoholics with depression, this would be of clinical importance. Methods: We conducted a randomized, 12-week placebo-controlled trial of imipramine hydrochloride combined with weekly relapse prevention psychotherapy. The subjects were 69 actively drinking alcoholic outpatients with current depressive disorders. The first onset of depression was either antecedent to the abuse of alcohol or occurred during prolonged periods of sobriety. Depression and drinking outcomes at 12 weeks, as well as their relationship, were measured. Results: Imipramine treatment was safe and associated with improvement in depression in both adequately treated and intention-to-treat samples. While there was no overall effect on drinking outcome, patients whose mood improved showed decreased alcohol consumption that was more marked in those treated with imipramine. Conclusions: Imipramine treatment is effective for primary depression among actively drinking alcoholic outpatients, and may improve alcoholic outcome for those whose depression responds to treatment.

The dropout rates among cocaine abusers in outpatient treatment programs have averaged 55%. We sought to find patient predictor variables associated with early attrition. Dropouts were more likely to be African-American or Hispanic-American, younger, with an earlier onset of substance abuse. Among minorities, those with more education were less likely to drop out. Patients who were less educated and smoked or injected cocaine were particularly prone to discontinue treatment prematurely. The implications of these findings, and promising interventions for reducing the dropout problem, are discussed.

Of 60 cocaine misusers seeking outpatient treatment, 33 (55%) dropped out by 4 weeks. Dropouts were more likely to be male, Black or Hispanic, or with no history of primary depression. Completers were more likely to be White, female, or depressed. The implications of these findings and possible strategies for reducing the dropout rate are discussed.

Background: We attempt to identify the time when patients whose conditions are unimproved while receiving antidepressants are unlikely to respond and should have their treatment changed. Methods: A total of 593 patients were studied. The course of treatment for patients was examined to determine the weeks at which patients who received drug therapy had a better chance of being rated as responders at the study end (week 6) vs patients who received placebo. Results: At the end of week 3, 19 (32%) of the 59 patients who received drug therapy and 6 (10%) of the 57 patients who received placebo and who never minimally improved were rated as responders at week 6. For those who showed no improvement by week 4, the effects of drug therapy and the placebo were equal. Patients who received drug therapy and whose conditions were unimproved but who had been minimally improved at some point had a superior prognosis with drug therapy vs placebo until week 4. Of those unimproved at week 4 but minimally improved at some point previously, 20 (39%) of the 51 patients who received drug therapy vs 3 (8%) of the 36 patients who received pIacebo were rated as responders at week 6. Of the 75 patients who minimally improved while receiving drug therapy at the end of week 5, 33 (44%) had a chance of being rated a responder at the end of week 6 vs 9 (26%) of the 35 patients receiving placebo. Conclusions: Patients tolerant of an adequate dose, whose conditions have never been at least minimally improved by the end of week 4, should have their treatment regimen altered. These patients represented a minority of drug-treated patients in the sample studied (ie, 39/392 [10%]). Patients whose conditions minimally improve at some prior week but not after week 5 should have their treatment changed. Patients whose conditions minimally improve in week 5 should continue treatment until week 6.

As a partial test of whether the same or different patients benefit from cognitive therapy and tricyclic antidepressant agents, depressed outpatients first received cognitive therapy, then nonresponders were treated with either imipramine or placebo. If the two treatments were effective for the same subgroup of patients, imipramine should not be more effective than placebo because potential responders should already have been removed by treatment with cognitive therapy. Alternatively, if cognitive therapy and imipramine are effective for different subtypes of depressive disorder, then imipramine ought to be more effective than placebo for patients failing to benefit from cognitive therapy because some potential imipramine failures would already have been removed. Thirty-six depressed outpatients were treated with weekly cognitive therapy for 16 weeks with 17 (47%) responding. Nonresponders were then randomly assigned to imipramine or placebo for 6 weeks to a maximum dose of 300 mg of imipramine per day. Of 12 patients completing the double-blind medication trial, all 5 assigned to imipramine had a clear-cut response, whereas none of the other seven benefited from placebo (chi 2 = 12.00; p = 0.001). Although the numbers are small, these results suggest rejection of the hypothesis that imipramine is effective for the same subpopulation of depressed patients as is cognitive therapy.