The combination of substance dependence and anxiety disorders is recognized to be increasingly common. It seems likely that substance misuse can activate new psychiatric disorders and aggravate the current disorder. It also seems that the presence of an anxiety or substance dependence disorder is a risk factor for the presence of another disorder.1
Individuals primarily treated for an alcohol or drug use disorder, are more likely to suffer from a comorbid anxiety disorder, because of substances inducing anxiety symptoms.2 Prevalence of anxiety disorders assessed was high in substance-dependent–treated persons with a lifetime prevalence that ranged from 26% to 35%. Among anxiety disorders, phobic and social anxiety disorders have been shown to often precede the onset of opiate dependence.3
The presence of anxiety disorders in heroin users is a robust finding. Anxiety disorders rates of between 16% and 38% are seen in narcotic addicts.4 A disturbingly high proportion of heroin users, meet the criteria for benzodiazepine dependence and anxiety disorders, a condition that should be regarded as a significant marker for comorbidity among this group.5
In contrast, severely anxious people are at high risk for opiates, alcoholism, smoking, and other forms of addiction. People with anxiety disorders, such as social phobia, generalized anxiety, panic, agoraphobia without history of panic, and specific phobia disorders, often misuse alcohol and prescription (eg, benzodiazepines) and/or illicit drugs (eg, stimulants or cannabinoids), developing substance abuse or dependence.2
The causal relationship between anxiety disorders and substance use as self-medication theories and substance-induced anxiety are not clearly established. Precipitation, self-medication as well as shared vulnerability are all viable pathways between nonmedical prescription opiate use and opiate use disorder due to nonmedical opiate use with anxiety disorders.6
Comorbidity of anxiety disorder and substance misuse has been associated with increased admission, suicidal behavior, and poor treatment outcome in both anxiety and substance misuse treatment populations. Symptoms of one disorder can contribute to relapse of the other disorder (eg, increased anxiety may lead the patient to drug or alcohol use to ameliorate symptoms).7
Thus, it is obvious that substance dependence and anxiety disorders commonly co-occur at different stages of both illnesses. Our interest in this work is to focus on the recovery period of patients with substance dependence. We aim to (a) assess the presence of anxiety disorders in recovered patients with substance dependence and (b) determine the common types of anxiety disorders among these patients at this phase of treatment.
MATERIALS AND METHODS
This is a descriptive longitudinal study that was conducted from May 2015 to April 2017. Patients (aged 20 to 40 y) who were diagnosed as having substance dependence disorder by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disease fourth edition (SCID-I) Arabic version by Hatata et al8 were assessed twice. Baseline assessment was carried out at 1-month abstinence from substance intake, and a similar assessment was carried out 5 months later (ie, at ≥6 mo abstinence). The participants were recruited consecutively from outpatient clinics and the group therapy sessions held by the addiction unit at Kasr Al Ainy Psychiatry and Addiction Prevention Hospital. Subjects with acute or chronic illness and uncooperative individuals with intellectual disabilities or major cognitive problems who could not complete the questions were excluded from the study. All participants signed a written informed consent before participating in the study. The study was approved by the Scientific and Ethical Committees of the Psychiatry Department, Faculty of Medicine, Cairo University.
Materials and Procedure
Patients were interviewed using the Kasr Al Ainy psychiatric sheet to1 collect data about sociodemographics, the pattern of drug abuse of the patients as regards times of relapse, the main substance used, main intoxication symptoms, age of onset, the current duration of recovery, longest previous abstinence, past medical history, family history, treatment plan and commitment to treatment plan, and2 assessment of mental status. Diagnosis of anxiety disorders were confirmed by using SCID-I, Arabic version by Hatata et al.8 Urine screening test was carried out by all participants with the same multidrug screening kits under supervision of a nurse to ensure the right urine sample and was checked immediately by the laboratory supervisor at Kasr Al Ainy Psychiatry and Addiction Hospital.
Data were coded and entered using the statistical package SPSS (Statistical Package for the Social Sciences) version 24. Data were summarized using mean±SD in quantitative data and using frequency (count/n) and relative frequency (percentage) for categorical data. The χ2 test was performed to compare categorical data. Exact test was used instead when the expected frequency was less than 5. P<0.05 were considered as statistically significant.9
In total, 106 patients with substance dependence disorder underwent the baseline assessment at 1-month abstinence of substance intake. The patients were advised to attend follow-up at the outpatient clinic and to attend the twice weekly group therapy of the addiction unit that was held at the Kasr Al Ainy Psychiatry and Addiction Prevention Hospital. At the ≥6-month assessment, 56 patients were excluded from enrolment in the study, wherein 18 patients had positive results on urine screening for different substances, 15 patients had residual psychotic features, 8 patients had comorbid mood disorder/symptoms, 6 patients reported recent substance use, 5 patients were suspected for recent substance use by their medical team and/family, and 4 patients had refused to continue the assessment. The mean±SD age for the remaining 50 patients was 30.24±5.74 years. Other participants’ characteristics are represented in Table 1.
Heroin and tramadol were the frequent main substances of dependence used by patients in our sample. The mean age of onset of substance intake was at 19.99±2.06 years. The mean duration of recovery was 278.24±16.70 days. The mean number of previous relapses was 4.18±2.75 times with the mean period of the longest previous abstinence being 140±101.02 days. An overall 42% of the patients did not report symptoms of intoxication. An overall 28% of the patients had convulsions during intoxication. Patients had received various management plans (eg, including medications, and individual and group psychotherapies) wherein 78% of them had regular commitment to their management plan (Table 2).
Diagnosis of Anxiety Disorders
At baseline assessment, the prevalence of anxiety disorders was 6%; however, it rose to 94% after 6 months’ abstinence. Specific phobic disorder was the most common anxiety disorder (20%), followed by social anxiety disorder (18%). Percentages of other anxiety disorders are represented in Table 3.
Association Between the Type of Main Substance Use and Anxiety Disorder
The majority of patients (60.9%) with heroin dependence, 50% of patients with cannabinoid dependence, and 34.8% with tramadol dependence had anxiety disorders after 6 months’ abstinence. Most of those patients had comorbid anxiety disorders. There was a statistically high significant relation between the main type of substance use and generalized anxiety disorder in recovered patients (P=0.005). An overall 50% of patients who were using cannabinoids and 26.1% who were using heroin had generalized anxiety disorder. There was insignificant association between type of main substance use and other types of anxiety disorders (Table 4).
The results of this study showed a high prevalence (94%) of anxiety disorders in recovered patients with ≥6 months abstinence from substance dependence. Specific phobic disorder was the most common anxiety disorder (20%) in these patients. There was statistically high significant relation between the main type of substance used and generalized anxiety disorder.
Our results were comparable to the results from the National Epidemiologic Survey on substance dependence and related conditions by Grant et al,10 who stated that the prevalence of DSM-IV anxiety disorders, among respondents with DSM-IV substance use disorders, who achieved recovery in the past 12 months, was 42.63%. Associations between substance use disorder and anxiety disorders were statistically positive and significant (P<0.05).
Our finding that 60.9% of the patients who recovered from heroin dependence had an anxiety disorder also corresponded to that of Fatséas et al3 who stated that the prevalence of anxiety disorders was high in persons who recovered from opiate use with a prevalence that ranged from 26% to 35%. Similarly, Grenyer et al4 reported that anxiety disorder rates were between 16% and 38% in narcotic abstinence.
The difference in prevalence rates of anxiety disorders in the above studies might be related to many considerations. Duration of abstinence, variations in patients’ vulnerability, lifestyle, and exposure to different life stressors may predispose to different categories of disorders and different types of anxiety disorders. Moreover, culture had a significant impact on determining the type of substance use and hence affects the development of related or comorbid disorders. For instance, alcohol dependence and alcohol-related disorders are much more common in the western countries than in the Arab countries. This may be due to religious and economic factors that may affect the availability of the substance itself. In contrast, Arab countries, especially Egypt, have an abundance of cannabinoids, tramadol, and heroin. Misusing >1 substance at the same time or at near time intervals might have also added to the ambiguity of development of comorbidity.
Another important factor that should not be overlooked in our sample was the sex difference. Male patients constituted 80% of the sample population. This inclination largely reflected our Egyptian culture. On one hand, the diagnosis of substance dependence disorders seemed to be more likely in male subjects. In contrast, even female patients, with substance dependence disorder, do not declare their problem or seek treatment, due to the fear of stigma, not only to her but to her whole family. The culturally sensitive substance abuse intervention, and stigma around substance use in female individuals in our society, may mask the real distribution in sex and affect long-term follow-up, as in recovery. Besides that, most families prefer to treat female individuals at home, without exposure to rehabilitation centers. Moreover, many female individuals face financial troubles, unlike male individuals who had relatively easy access to work and gain money to be involved in recovery management programs. We believe that this discrepancy in the sex has added to the different prevalence rates of anxiety disorders, or at least the type of the anxiety disorder.
Despite these considerations, it was observed that the differences were not affecting the fact of the actual presence of anxiety disorders, in recovered patients with substance dependence disorders after 6 months abstinence, and that anxiety disorder could be considered as a risk factor and an important comorbidity. Thus, our results highlight the need, for all individuals under treatment, to be fully assessed for the presence or absence of a range of psychiatric disorders, mainly anxiety disorders. Moreover, these results strongly suggest that, treatment for anxiety disorder should not be withheld from those with substance dependence disorders in stable remission, on the assumption that most of these disorders are due to intoxication or withdrawal. Left untreated, such anxiety disorders could lead to relapse of substance dependence.
Specific phobic disorder (20%), social anxiety disorder (18%), and generalized anxiety disorder (16%) were the most common anxiety disorders in the sample. This was matched with Grant et al10 who stated similar results in a study of 12 months prevalence of DSM-IV-independent anxiety disorders among respondents with DSM-IV substance use disorders. The results of the National Epidemiologic Survey revealed that any anxiety disorder represented 42.63%, specific phobia 22.52%, generalized anxiety disorder 22.07%, and social phobia 12.09%. Different prevalence rates were found by Boschloo et al,11 wherein baseline data from the Netherlands Study of Depression and Anxiety (NESDA) found that drug addiction had a prevalence of 6.5%, 4.4%, 3.7%, and 2.8% among individuals suffering from panic disorder, social phobia, agoraphobia, and obsessive-compulsive disorder, respectively. Brady and Kendall12 found that lifetime posttraumatic stress disorder rates ranged from 30% to >60% in abstinent substance use disorder populations.
These differences may be explained by the differences in sample methodology, such as the wide range of age and bigger catchment area for the sample, as well as ethnic perspectives. Moreover, the difference in the duration of abstinence and the management plans in the studies may contribute to the differences in the prevalence of anxiety disorders and types among recovered patients.
The highly statistically significant relation (P=0.005) of the presence of generalized anxiety disorder in recovered cases with the main substance of use (heroin mainly and cannabinoids to a lesser extent) matched the findings of van Laar et al13 who highlighted a significant association between baseline cannabis use and 3-year incidence of any anxiety disorder (especially generalized anxiety and panic disorders). It was also supported by the work of Bolton et al14 who made the representative National Comorbidity Survey (NCS), which showed that self-medication with drugs in recovered patients was present in 21.9% of individuals with any anxiety disorder, with the highest prevalence (35.6%) among people with a generalized anxiety disorder.
An Egyptian study by Hamdi et al15 found that cannabis was the commonest used substance in all Egyptian regions. In total, 77% of the substance users were using cannabis. Alcohol (28.6% of total use) was the second common substance of use in all Egyptian governorates, except in Upper Egypt (where the opiates were commoner than alcohol). Meanwhile, in governorates outside the Upper Egypt region, opiates were the third common substance of use in Egypt (23.4% of total use). Indeed, our everyday clinical practice approves this finding. However, our sample showed that the use of heroin and tramadol (46% each) was much more than that of cannabinoids (8%). This could be explained by the fact that, our sample represented recovered patients with ≥6 months of abstinence, that is, most cannabis abusers did not seek psychiatric help, as they were relatively functioning, and cannabis was considered as a part of their normal life. Besides, in this study, we focused on the main substance of use, not considering secondary substances.
From another perspective, Domino et al16 reported that the drug of choice in recovered cases was alcohol (56%), opioids (23%), cocaine (3%), benzodiazepines (2%), and other drugs represented (7%). Moreover, Lee et al17 found that the most prevalent substance used was cocaine (42.1%), followed by alcohol (36.8%), sedatives (21.1%), opiates (21.1%), marijuana (5.3%), amphetamine (5.3%), and then phencyclidine (5.3%). The discrepancy in representation of the primary substance may be related to the availability of substances, lifestyle, financial resources, religious aspects, and different cultural norms between Egyptian and western communities. Despite these facts, our results pointed to an alarming trend toward increasing heroin use. More education about this increasing prevalence and the risks of different ways of intake is demanded.
Surprisingly, we found low prevalence (6%) of anxiety disorders at the baseline assessment (at 1-month abstinence). This might be attributed to many factors. First, nearly all patients at this time had been just discharged from the hospital after the detoxification period. Second, patients at this stage used to take and comply on multiple medications with higher dosage than that at/after the 6-month abstinence period. Lastly, assessments were mainly based on the SCID for DSM-IV, which diagnosed full-blown disorders. Thus, subthreshold clinical symptoms would have been overlooked at 1-month abstinence.
From an etiologic perspective, this study did not resolve questions with regard to the causal mechanisms underlying the relationship between DSM-IV substance dependence disorders and independent anxiety disorders. Longer prospective surveys have great potential to inform us about processes associated with comorbidity and would provide the vehicles for examining the sequencing of comorbid disorder onset.
The issue of comorbidity between mental disorders (here anxiety disorder) and substance dependence disorders is demanding attention from researchers, clinicians, and policy makers. Despite this demand, there is very little guidance to date with regard to best practice for individuals with >1 disorder.
The authors thank the patients who were able and keen to complete the study.
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