Three new antidepressants have been marketed in the United States since 1980, and about two dozen... more Three new antidepressants have been marketed in the United States since 1980, and about two dozen more are being evaluated. In a 1983 workshop convened by the National Institute of Mental Health, participants examined the claims made for the newer antidepressants in relation to clinical efficacy, speed of onset, cardiovascular effects, and other adverse reactions. In this summary report of the workshop, primarily covering amoxapine, maprotiline, trazodone, and the investigational drug bupropion, the authors note that none of the new antidepressants demonstrate greater effectiveness than standard tricyclics, although some produce a different profile of side effects. The main benefit of the newer drugs is that they offer new options for the treatment of patients who cannot tolerate side effects of the traditional drugs or have responded unsatisfactorily to them.
Annals of the New York Academy of Sciences, Mar 1, 1986
The mechanism of action of convulsive therapy has been questioned and investigated since the firs... more The mechanism of action of convulsive therapy has been questioned and investigated since the first therapeutic use of induced seizures by Meduna in 1935.’ Meduna believed that biological antagonism existed between the process that produces epilepsy and the process that produces schizophrenia. Thus, he thought that an induced convulsion in man would change brain chemistry in a therapeutic manner. When, in 1938, Cerletti and Bini introduced the use of electrically induced convulsions: they believed that the seizure was the fundamental therapeutic factor while the electricity was only the epileptogenic stimulus. In 1960, Ottosson and associates reported on a series of studies in which energy of electrical stimulation and cerebral seizure activity were systematically and independently manipulated experimentally to carefully delineate the specific effects of the electrical stimulation and seizure activity.’ They concluded that the therapeutic and cognitive effects of electroconvulsive therapy (ECT) arise through different mechanisms. The therapeutic effect “is due to seizure activity and not, or only slightly, to the other effects of the c~ r ren t . ”~ The memory disturbance is to a great extent accounted for by the effects of the electrical stimulation other than the seizure. Over the years of extensive ECT usage, a variety of theories or explanations have been forthcoming to attempt to ascribe the therapeutic effect of ECT to other causes including the occurrence of structural brain changes and psychological theories focusing on fear, punishment, amnesia, denial, repression, and ego adaptation.‘ No evidence is available supporting any of these theories. However, primacy of the generalized seizure itself has been confirmed clearly and repeatedly over the last 10 years in a series of controlled clinical trials comparing ECT and sham ECT (simulated ECT in which all elements of the treatment, including general anesthesia and muscle relaxant, are given except for the electrical Contemporary clinical therapy and most research on ECT have been guided by these basic assumptions. In recent years, basic and clinical scientists have intensified research efforts to better understand the mechanism of action of ECT by delineating the specific alterations in brain biological functioning brought about by a series of electrically induced generalized seizures that serve to relieve depression in man. As a result, a wealth of information is available on the effects of ECT on brain biological function from a multitude of vantage points including the neurophysiology, neuroendocrinology, neurochemistry, and neuroreceptorology. Much of this work, which has been presented earlier in this volume, has been based on basic studies employing electroconvulsive shocks in rodents. Human clinical studies attempting to clarify the
We sought to determine the prevalence, patterns, and correlates of past-month illicit methadone u... more We sought to determine the prevalence, patterns, and correlates of past-month illicit methadone use and history of regular illicit use among stimulant-using methadone maintenance treatment patients. We obtained self-reported information on illicit methadone use from 383 participants recruited from six community-based methadone maintenance programs. Overall, 1.6% of participants reported illicit use in the past month, and 4.7% reported a history of regular use. Younger age and history of outpatient psychological treatment were associated with increased odds of past-month illicit use. Illicit methadone use among patients in maintenance programs is infrequent; however, a number of factors may increase risk of illicit use. The misuse and abuse of opioids has emerged as a major health issue in the United States. 1 Approximately 227,000 Americans met criteria for past-year heroin abuse or dependence, and 1.5 million Americans abused or were dependent on prescription opioids (eg, oxycodone [OxyContin ® ], hydromorphone [Dilaudid ® ], and hydrocodone) in 2005. 2 The financial cost of untreated opioid dependence to individual users, their families, and society at large is estimated to be approximately $20 billion annually. 3 Methadone is a synthetic, long-acting opioid agonist approved for treatment of chronic pain and opioid addiction. 4 Since the first study conducted by Dole and Nyswander, 5 methadone maintenance therapy has been one of the most widely used treatments for opioid addiction, and methadone maintenance treatment decreases heroin and other drug use, criminal activity, medical comorbidity, HIV transmissions, and mortality. 3,6 Prior to 2003, an estimated 97% of patients treated with opioid agonist medications received methadone; the remaining 3% received levo-alpha-acetyl-methadol (LAAM). 7 Although LAAM was approved for use by the Food and Drug Administration, the manufacturer discontinued the sale and distribution of LAAM in the United States in 2003 due to reports of severe cardiac-related adverse events. 8 Since 2002, sublingual preparations of the partial opioid
There are ethical concerns as well as fear of litigation about clinical studies in pregnant patie... more There are ethical concerns as well as fear of litigation about clinical studies in pregnant patients. Therefore, institutional review board (IRB) approval sometimes is difficult. The reluctance of pharmaceutical companies to develop medications for this population probably is due to the concern over financial feasibility and fear of litigation. Orphan drug status could provide some incentive to the industry. Federal Government agencies should encourage research in this area by providing sufficient funds to scientific communities, by facilitating IRB approval, and by actively collaborating with industry and interacting with FDA to advance medications development. Research is urgently needed to develop treatments for pregnant drugdependent women and their infants. A multidisciplinary approach is essential for medications development, and a comprehensive treatment program is necessary for the success of the treatment of pregnant addicts.
A total of 33,384 hospitalized patients were treated with ECT in 1 980, representing 2.4% of all ... more A total of 33,384 hospitalized patients were treated with ECT in 1 980, representing 2.4% of all patients hospitalized in psychiatric facilities. The use of ECT decreased by 46% between 1 975 and 1 980. Of the type of facilities surveyed, only public general hospitals did not decrease their use of ECT. Patients with affective disorders received 69.8% of the ECT given, and patients with schizophrenia received 16.6%. Although more women than men received ECT, diagnosis and age were more important factors than sex.
This research attempt to clarify and quantify the ways in which heroin addicts deal with interper... more This research attempt to clarify and quantify the ways in which heroin addicts deal with interpersonal relations. A sample of heroin addicts on a methadone maintenance program were given the Fundamental Interpersonal Relations Orientation-Behavior (FIRO-B) scale. An accidental sample consisted of 35, approximately one-half, of the clinic's population. A mean interpersonal orientation profile is established and interpreted. An analysis of variance was performed for each of the six FIRO-B scores. Patients needs based on FIRO-B scores are discussed with regard to the descriptions of addicts life-styles as described in the literature. The possible etiological basis for these interpersoanl orientations is also discussed. Several therapeutic approaches, as indicated by FIRO-B scores, are explored.
Journal of Studies on Alcohol and Drugs, May 1, 2009
The aim of this study was to examine psychometric properties of the Diagnostic and Statistical Ma... more The aim of this study was to examine psychometric properties of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), diagnostics criteria for alcohol and marijuana dependences among 462 alcohol users and 311 marijuana users enrolled in two multisite trials of the National Drug Abuse Treatment Clinical Trials Network. Method: Diagnostic questions were assessed by the DSM-IV checklist. Data were analyzed by the item response theory and the multiple indicators-multiple causes method procedures. Results: Criterion symptoms of alcohol and marijuana dependences exhibited a high level of internal consistency. All individual symptoms showed good discrimination in distinguishing alcohol or marijuana users between high and low severity levels of the continuum. In both groups, "withdrawal" appeared to measure the most severe symptom of the dependence continuum. There was little evidence of measurement nonequivalence in assessing symptoms of dependence by gender, age, race/ethnicity, and educational level. Conclusions: These findings highlight the clinical utility of the DSM-IV checklist in assessing alcohol-and marijuanadependence syndromes among treatment-seeking substance users. (J.
Introduction-Although DSM-IV criteria are widely used in making diagnoses of substance use disord... more Introduction-Although DSM-IV criteria are widely used in making diagnoses of substance use disorders, gaps exist regarding diagnosis classification, use of dependence criteria, and effects of measurement bias on diagnosis assessment. We examined the construct and measurement equivalence of diagnostic criteria for cocaine and opioid dependences, including whether each criterion maps onto the dependence construct, how well each criterion performs, how much information each contributes to a diagnosis, and whether symptom-endorsing is equivalent between demographic groups. Methods-Item response theory (IRT) and multiple indicators-multiple causes (MIMIC) modeling were performed on a sample of stimulant-using methadone maintenance patients enrolled in a multisite study of the National Drug Abuse Treatment Clinical Trials Network (CTN) (N=383). Participants were recruited from six community-based methadone maintenance treatment programs associated with the CTN and major U.S. providers. Cocaine and opioid dependences were assessed by DSM-IV Checklist. Results-IRT modeling showed that symptoms of cocaine and opioid dependences, respectively, were arrayed along a continuum of severity. All symptoms had moderate to high discrimination in distinguishing drug users between severity levels. "Withdrawal" identified the most severe symptom
Levo-alpha-acetylmethadol (LAAM) is a derivative of methadone not inappropriately referred to by ... more Levo-alpha-acetylmethadol (LAAM) is a derivative of methadone not inappropriately referred to by patients as “long-acting methadone.” While LAAM was originally developed during World War II as an analgesic, it was found to be inappropriate for that purpose due to the slow-acting onset of its psychoactivity. Further testing of the drug was delayed until the early 1950’s when Isbell and Fraser (Fraser and Isbell, 1952; Fraser, Nash, Vanhorn, and Isbell, 1954) demonstrated the drug’s opiate-like profile. LAAM was found by them to be equally as efficacious as methadone in preventing the occurrence of withdrawal symptoms in morphine dependent subjects. Furthermore, since LAAM has an extremely long duration of action which can persist over 72 hours after a single oral dose it can be clearly advantageous for use in drug-dependent individuals.
Methamphetamine use continues to be an important public health problem. Contingency management is... more Methamphetamine use continues to be an important public health problem. Contingency management is among the most effective interventions for reducing methamphetamine use. It has been more than ten years since the last systematic review of contingency management for methamphetamine use disorder. Since then, an additional ten randomized controlled trials and a variety of other studies have been completed. The present systematic review includes 27 studies. Several factors, most notably problem severity, appear to predict treatment outcome. However, the effectiveness of CM has been demonstrated in studies restricted to MSM, studies restricted to implementation in community programs, and in studies of the general population of methamphetamine users conducted in research treatment programs. There appear to be broad benefits of contingency management intervention, including greater drug abstinence, higher utilization of other treatments and medical services, and reductions in risky sexual behavior. Twenty of the twenty-one studies that reported abstinence outcomes showed an effect of contingency management on abstinence, and seven of the nine studies that reported sexual risk behavior outcomes showed an effect of contingency management in reducing risky sexual behavior. Taken together, recent evidence suggests strongly that outpatient programs that offer treatment for methamphetamine use disorder should prioritize adoption and implementation of contingency management intervention.
Three new antidepressants have been marketed in the United States since 1980, and about two dozen... more Three new antidepressants have been marketed in the United States since 1980, and about two dozen more are being evaluated. In a 1983 workshop convened by the National Institute of Mental Health, participants examined the claims made for the newer antidepressants in relation to clinical efficacy, speed of onset, cardiovascular effects, and other adverse reactions. In this summary report of the workshop, primarily covering amoxapine, maprotiline, trazodone, and the investigational drug bupropion, the authors note that none of the new antidepressants demonstrate greater effectiveness than standard tricyclics, although some produce a different profile of side effects. The main benefit of the newer drugs is that they offer new options for the treatment of patients who cannot tolerate side effects of the traditional drugs or have responded unsatisfactorily to them.
Annals of the New York Academy of Sciences, Mar 1, 1986
The mechanism of action of convulsive therapy has been questioned and investigated since the firs... more The mechanism of action of convulsive therapy has been questioned and investigated since the first therapeutic use of induced seizures by Meduna in 1935.’ Meduna believed that biological antagonism existed between the process that produces epilepsy and the process that produces schizophrenia. Thus, he thought that an induced convulsion in man would change brain chemistry in a therapeutic manner. When, in 1938, Cerletti and Bini introduced the use of electrically induced convulsions: they believed that the seizure was the fundamental therapeutic factor while the electricity was only the epileptogenic stimulus. In 1960, Ottosson and associates reported on a series of studies in which energy of electrical stimulation and cerebral seizure activity were systematically and independently manipulated experimentally to carefully delineate the specific effects of the electrical stimulation and seizure activity.’ They concluded that the therapeutic and cognitive effects of electroconvulsive therapy (ECT) arise through different mechanisms. The therapeutic effect “is due to seizure activity and not, or only slightly, to the other effects of the c~ r ren t . ”~ The memory disturbance is to a great extent accounted for by the effects of the electrical stimulation other than the seizure. Over the years of extensive ECT usage, a variety of theories or explanations have been forthcoming to attempt to ascribe the therapeutic effect of ECT to other causes including the occurrence of structural brain changes and psychological theories focusing on fear, punishment, amnesia, denial, repression, and ego adaptation.‘ No evidence is available supporting any of these theories. However, primacy of the generalized seizure itself has been confirmed clearly and repeatedly over the last 10 years in a series of controlled clinical trials comparing ECT and sham ECT (simulated ECT in which all elements of the treatment, including general anesthesia and muscle relaxant, are given except for the electrical Contemporary clinical therapy and most research on ECT have been guided by these basic assumptions. In recent years, basic and clinical scientists have intensified research efforts to better understand the mechanism of action of ECT by delineating the specific alterations in brain biological functioning brought about by a series of electrically induced generalized seizures that serve to relieve depression in man. As a result, a wealth of information is available on the effects of ECT on brain biological function from a multitude of vantage points including the neurophysiology, neuroendocrinology, neurochemistry, and neuroreceptorology. Much of this work, which has been presented earlier in this volume, has been based on basic studies employing electroconvulsive shocks in rodents. Human clinical studies attempting to clarify the
We sought to determine the prevalence, patterns, and correlates of past-month illicit methadone u... more We sought to determine the prevalence, patterns, and correlates of past-month illicit methadone use and history of regular illicit use among stimulant-using methadone maintenance treatment patients. We obtained self-reported information on illicit methadone use from 383 participants recruited from six community-based methadone maintenance programs. Overall, 1.6% of participants reported illicit use in the past month, and 4.7% reported a history of regular use. Younger age and history of outpatient psychological treatment were associated with increased odds of past-month illicit use. Illicit methadone use among patients in maintenance programs is infrequent; however, a number of factors may increase risk of illicit use. The misuse and abuse of opioids has emerged as a major health issue in the United States. 1 Approximately 227,000 Americans met criteria for past-year heroin abuse or dependence, and 1.5 million Americans abused or were dependent on prescription opioids (eg, oxycodone [OxyContin ® ], hydromorphone [Dilaudid ® ], and hydrocodone) in 2005. 2 The financial cost of untreated opioid dependence to individual users, their families, and society at large is estimated to be approximately $20 billion annually. 3 Methadone is a synthetic, long-acting opioid agonist approved for treatment of chronic pain and opioid addiction. 4 Since the first study conducted by Dole and Nyswander, 5 methadone maintenance therapy has been one of the most widely used treatments for opioid addiction, and methadone maintenance treatment decreases heroin and other drug use, criminal activity, medical comorbidity, HIV transmissions, and mortality. 3,6 Prior to 2003, an estimated 97% of patients treated with opioid agonist medications received methadone; the remaining 3% received levo-alpha-acetyl-methadol (LAAM). 7 Although LAAM was approved for use by the Food and Drug Administration, the manufacturer discontinued the sale and distribution of LAAM in the United States in 2003 due to reports of severe cardiac-related adverse events. 8 Since 2002, sublingual preparations of the partial opioid
There are ethical concerns as well as fear of litigation about clinical studies in pregnant patie... more There are ethical concerns as well as fear of litigation about clinical studies in pregnant patients. Therefore, institutional review board (IRB) approval sometimes is difficult. The reluctance of pharmaceutical companies to develop medications for this population probably is due to the concern over financial feasibility and fear of litigation. Orphan drug status could provide some incentive to the industry. Federal Government agencies should encourage research in this area by providing sufficient funds to scientific communities, by facilitating IRB approval, and by actively collaborating with industry and interacting with FDA to advance medications development. Research is urgently needed to develop treatments for pregnant drugdependent women and their infants. A multidisciplinary approach is essential for medications development, and a comprehensive treatment program is necessary for the success of the treatment of pregnant addicts.
A total of 33,384 hospitalized patients were treated with ECT in 1 980, representing 2.4% of all ... more A total of 33,384 hospitalized patients were treated with ECT in 1 980, representing 2.4% of all patients hospitalized in psychiatric facilities. The use of ECT decreased by 46% between 1 975 and 1 980. Of the type of facilities surveyed, only public general hospitals did not decrease their use of ECT. Patients with affective disorders received 69.8% of the ECT given, and patients with schizophrenia received 16.6%. Although more women than men received ECT, diagnosis and age were more important factors than sex.
This research attempt to clarify and quantify the ways in which heroin addicts deal with interper... more This research attempt to clarify and quantify the ways in which heroin addicts deal with interpersonal relations. A sample of heroin addicts on a methadone maintenance program were given the Fundamental Interpersonal Relations Orientation-Behavior (FIRO-B) scale. An accidental sample consisted of 35, approximately one-half, of the clinic's population. A mean interpersonal orientation profile is established and interpreted. An analysis of variance was performed for each of the six FIRO-B scores. Patients needs based on FIRO-B scores are discussed with regard to the descriptions of addicts life-styles as described in the literature. The possible etiological basis for these interpersoanl orientations is also discussed. Several therapeutic approaches, as indicated by FIRO-B scores, are explored.
Journal of Studies on Alcohol and Drugs, May 1, 2009
The aim of this study was to examine psychometric properties of the Diagnostic and Statistical Ma... more The aim of this study was to examine psychometric properties of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), diagnostics criteria for alcohol and marijuana dependences among 462 alcohol users and 311 marijuana users enrolled in two multisite trials of the National Drug Abuse Treatment Clinical Trials Network. Method: Diagnostic questions were assessed by the DSM-IV checklist. Data were analyzed by the item response theory and the multiple indicators-multiple causes method procedures. Results: Criterion symptoms of alcohol and marijuana dependences exhibited a high level of internal consistency. All individual symptoms showed good discrimination in distinguishing alcohol or marijuana users between high and low severity levels of the continuum. In both groups, "withdrawal" appeared to measure the most severe symptom of the dependence continuum. There was little evidence of measurement nonequivalence in assessing symptoms of dependence by gender, age, race/ethnicity, and educational level. Conclusions: These findings highlight the clinical utility of the DSM-IV checklist in assessing alcohol-and marijuanadependence syndromes among treatment-seeking substance users. (J.
Introduction-Although DSM-IV criteria are widely used in making diagnoses of substance use disord... more Introduction-Although DSM-IV criteria are widely used in making diagnoses of substance use disorders, gaps exist regarding diagnosis classification, use of dependence criteria, and effects of measurement bias on diagnosis assessment. We examined the construct and measurement equivalence of diagnostic criteria for cocaine and opioid dependences, including whether each criterion maps onto the dependence construct, how well each criterion performs, how much information each contributes to a diagnosis, and whether symptom-endorsing is equivalent between demographic groups. Methods-Item response theory (IRT) and multiple indicators-multiple causes (MIMIC) modeling were performed on a sample of stimulant-using methadone maintenance patients enrolled in a multisite study of the National Drug Abuse Treatment Clinical Trials Network (CTN) (N=383). Participants were recruited from six community-based methadone maintenance treatment programs associated with the CTN and major U.S. providers. Cocaine and opioid dependences were assessed by DSM-IV Checklist. Results-IRT modeling showed that symptoms of cocaine and opioid dependences, respectively, were arrayed along a continuum of severity. All symptoms had moderate to high discrimination in distinguishing drug users between severity levels. "Withdrawal" identified the most severe symptom
Levo-alpha-acetylmethadol (LAAM) is a derivative of methadone not inappropriately referred to by ... more Levo-alpha-acetylmethadol (LAAM) is a derivative of methadone not inappropriately referred to by patients as “long-acting methadone.” While LAAM was originally developed during World War II as an analgesic, it was found to be inappropriate for that purpose due to the slow-acting onset of its psychoactivity. Further testing of the drug was delayed until the early 1950’s when Isbell and Fraser (Fraser and Isbell, 1952; Fraser, Nash, Vanhorn, and Isbell, 1954) demonstrated the drug’s opiate-like profile. LAAM was found by them to be equally as efficacious as methadone in preventing the occurrence of withdrawal symptoms in morphine dependent subjects. Furthermore, since LAAM has an extremely long duration of action which can persist over 72 hours after a single oral dose it can be clearly advantageous for use in drug-dependent individuals.
Methamphetamine use continues to be an important public health problem. Contingency management is... more Methamphetamine use continues to be an important public health problem. Contingency management is among the most effective interventions for reducing methamphetamine use. It has been more than ten years since the last systematic review of contingency management for methamphetamine use disorder. Since then, an additional ten randomized controlled trials and a variety of other studies have been completed. The present systematic review includes 27 studies. Several factors, most notably problem severity, appear to predict treatment outcome. However, the effectiveness of CM has been demonstrated in studies restricted to MSM, studies restricted to implementation in community programs, and in studies of the general population of methamphetamine users conducted in research treatment programs. There appear to be broad benefits of contingency management intervention, including greater drug abstinence, higher utilization of other treatments and medical services, and reductions in risky sexual behavior. Twenty of the twenty-one studies that reported abstinence outcomes showed an effect of contingency management on abstinence, and seven of the nine studies that reported sexual risk behavior outcomes showed an effect of contingency management in reducing risky sexual behavior. Taken together, recent evidence suggests strongly that outpatient programs that offer treatment for methamphetamine use disorder should prioritize adoption and implementation of contingency management intervention.
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