Depressive symptoms differentiating between heroin addicts and alcoholics

Drug and Alcohol Dependence, 15 (1985) 145-150 Elsevier Scientific Publishers Ireland Ltd.

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DEPRESSIVE SYMPTOMS DIFFERENTIATING BETWEEN HEROIN ADDICTS AND ALCOHOLICS

ROBERT A. STEERa, AARON T. BECKb* and BRIAN F. SHAWC

aDepartment of Psychiatry, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Camden, NJ, bCenter for Cognitive Therapy, Department of Psychiatry, University of Pennsylvania, School of Medicine, Philadelphia, PA (U.S.A.) and ‘Department ofPsychiatry, University of Toronto, Toronto, Ontario (Canada)

(Received October 23rd, 1984)

SUMMARY

The Beck Depression Inventory (BDI) was self-administered to 105 outpatient alcoholics and 211 methadone maintenance patients seeking treatment at a large community mental health center to determine whether or not specific depressive symptoms differentiated the groups. Canonical correlations were first calculated between the set of 21 BDI items and the patients’ demographic characteristics of sex, race and age to ascertain if these characteristics should be controlled before making comparisons between the two types of substance abusers. Age and sex were significantly related to self-reported depressive symptomatology and were entered first into a stepwise discriminant analysis with the 21 BDI items followed by type of substance abuse. Four symptoms contributed at least 5% to the overall discrimination between the alcoholics and the heroin addicts; these were (1) sense of failure, (2) weight loss, (3) somatic preoccupation, and (4) loss of libido. The alcoholics described themselves as feeling more like failures and having more somatic preoccupation than the heroin addicts, whereas the heroin addicts reported more weight loss and loss of libido. To estimate the efficiency with which these four symptoms could differentiate between the alcoholics and heroin addicts, discriminant classification analysis was employed; 69.3% of the substance abusers were correctly assigned to their type of addiction. The results were discussed as supporting the contention that alcoholics and heroin addicts may display different depressive symptoms.

Key words: Dependence - Alcohol - Heroin - Depression

*To whom requests for reprints should be addressed at: Center for Cognitive Therapy, 133 South 36th, Street, Room 602, Philadelphia, PA, 19104, U.S.A.

0376~8716/85/$03.30 o 1985 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland

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Substantial research evidence has accumulated over the last 10 years indicating that depression is an important affective disorder confounding the treatment of alcoholism and heroin addiction [l-3]. In one study of heroin addicts [4], a significant amount of clinically observed symptomatology was explained by anxious-depressed features (35%), hostile- depressive features (16.9%) and psychomotor-retarded depressive features (9.5%). There is some evidence that the type of depressive symptoms du- played by heroin addicts differentiates them from other clinical populations [ 51, although most studies using only the severity of depression presented by heroin addicts are equivocal.

Depression has been described as prevalent in alcoholics [6]. Cadoret and Winokur [7] considered depression, whether primary or secondary and regardless of etiology, to be the most frequent affective disorder found in alcoholics. Vegetative symptoms of depression (e.g. loss of appetite, sleep impairment, loss of libido), however, are also associated with alcoholism per se. The sharing of such transdiagnostic symptoms has led to specula- tion that there is no unique depressive syndrome in alcoholism [ 81, but that the combination of depressive symptoms reported by alcoholics may be different from that described by other types of psychiatric patients.

The purpose of the present study was to investigate the self-reported depressive symptomatology in heroin addicts and alcoholics. In both of these groups, the physical-vegetative symptoms of depression may be im- plicated for reasons other than those associated with the syndrome (e.g. concomitants of substance abuse). The present study assessed whether or not specific symptoms of depression differentiated the heroin addict from the alcoholic.

METHOD

Samples Heroin addicts. The sample of heroin addicts was drawn from 211 con-

secutive admissions to a methadone-maintenance program. All of the addicts were using heroin on a daily basis, and none displayed manifest signs of withdrawal at the time of admission. There~ were 157 (74.4%) men and 54 (25.6%) women. One-third of the patients were white, and the remainder were black. The marital status varied: 45.4% were single, 27.5% were married, 26.1% were separated or divorced and 1% were widowed. Unemploy- ment was reported by 86.7% and 15.2% were living with other addicts. The mean age was 27.65 years (S.D. = 5.81), and the mean educational attainment was 11.01 years (S.D. = 1.63). None of the addicts admitted to previous treatment for mental health disorders, but 77.7% described previous treatment for drug abuse. Less than 7% had used any type of illicit substance, besides heroin, for the 2 months preceding admission. The modal additional drug of abuse was marijuana (6.2%), but only 3.3% admitted to smoking it daily.

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Alcoholics. The alcoholics were represented by 76 (72.4%) men and 29 (27.6%) women admitted to the outpatient alcoholism program of the same large community mental health center. The sample was 69.5% black and 30.5 white. The mean age was 37.99 (S.D. = 9.97) years, and the mean educational attainment was 10.51 (S.D. = 2.04) years. The marital status was 13.3% married, 5.7% widowed, 7.1% divorced, 30.5% separated and 33.3% single. Employment was reported by only 22.9% and 70.5% of the admissions were voluntary. Previous attendance at Alcoholics Anonymous meetings was reported by 38.1% and 49.5% described previous inpatient hospitalization for alcoholism within the past 6 months. The mean number of years of heavy drinking was 11.96 (SD. = 8.99). Only 15.5% admitted to the use of illicit drugs.

Instrument The BDI [9] was chosen at the instrument to measure the intensity of

self-reported depression. Each of the 21 BDI items is composed of four alternative statements rating severity from 0 to 3. The mean BDI scores were 13.88 (S.D. = 10.60) for the alcoholics and 13.18 (S.D. = 9.35) for the heroin addicts. The mean scores were comparable (t (314) = 0.55) and indicated only mild levels of depression [lo]. The BDI was administered at the time of admission during which a detailed intake interview was also completed by a trained clinician.

Data analysis Previous research on depression has indicated depressive symptoms

may differ with respect to sex, race and age [ 3,101. Therefore, canonical correlations were calculated between these three demographic characteristics, the type of substance abused (alcohol or heroin), and the set of 21 BDI items to ascertain which variables should be controlled for in sub- sequent analyses.

Table I presents the canonical correlations coefficients for the demo-

TABLE I

CANONICAL RELATIONSHIPS OF SEX, RACE, AGE AND TYPE OF SUBSTANCE ABUSE WITH THE 21 BDI ITEMS (n = 316)

*P < 0.05; **p < 0.01; ***p < 0.001.

Variable

Sex (1 = male, 2 = female) Race (1 = white, 2 = black) Age (years) Type of abuse

(1 = heroin, 2 = alcohol)

Canonical R’ Wilks ;\

0.12 0.88 0.11 0.90 0.12 0.89 0.25 0.75

F (21,294)

1.97** 1.58 1.68* 4.75***

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graphic characteristics and type of treatment. Age, sex and type of treatment being sought were significantly related to the set of BDI items.

Since the purpose of the present study was to determine whether or not the depressive characteristics differentiated between alcoholics and heroin addicts, it was decided to employ a stepwise discriminant analysis. Because age and sex were of only secondary interest as control variables, these were added first as covariates; the 21 BDI items which were sub- sequently entered were, therefore, controlled for the effects of sex and age. Because the BDI represents a unidimensional side of depression, its items are known to be highly intercorrelated [ 5,8]. Consequently, a backward elimination model was chosen for the stepwise discriminant analysis in which all of the 21 BDI items were added simultaneously into the regres- sion after the introduction of age and sex. Each item was then eliminated in a stepwise manner until only those variables contributing at least 5% to the overall discrimination between the alcoholics and heroin addicts remain- ed.

Finally, to ascertain the efficiency of the resultant depressive symptoms to differentiate between alcoholics and heroin addicts, a discriminant classification analysis was employed to determine how successfully each of the alcoholics and heroin addicts would be assigned to their respective groups.

RESULTS

Table II presents the stepwise discriminant analysis for the alcoholics and heroin addicts. The average squared canonical correlation was 0.41 (Wilks’ X = 0.59; F (5, 310) = 43.62, P<.OOl). The overall discrimination between the two groups afforded by four symptoms was significant beyond the 0.001 level, 2-tailed test; the four symptoms were (1) sense of failure, (2) weight loss, (3) somatic preoccupation and (4) loss of libido. The alcoholics described themselves as feeling more like failures and having more

TABLE II

BACKWARD STEPWISE DISCRIMINANT ANALYSIS OF THE BDI WITH HEROIN

ADDICTS AND ALCOHOLICS CONTROLLING FOR SEX AND AGE

Average canonical RZ = 0.41; Wilks’ A = 0.59; F (5,310) = 43.62;P < 0.001.

BDI item Partial R*

Sense of failure 0.07

Weight loss 0.08 Somatic preoccupation 0.05 Loss of libido 0.06

F ( 1,309)a

23.96

25.57 16.20 18.00

aAll Fs were significant beyond the 0.001 level, 2-tailed test.

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TABLE III

CLASSIFICATION OF HEROIN ADDICTS AND ALCOHOLICS BY DEPRESSIVE SYMPTOMS

Hit rate = 69.3%.

Actual Predicted

Heroin

n (%)

Alcohol

n (%)

Total

n (%)

Heroin 160 (50.6) 51 (16.1) 211 (66.7)

Alcohol 46 (14.6) 59 (18.7) 105 (33.3)

Total 206 (65.2) 110 (34.8) 316 (100.0)

somatic preoccupations than the heroin addicts, whereas the heroin addicts described more weight loss and loss of libido than the alcoholics.

A discriminant classification analysis was employed to ascertain how successful the reduced set of four depressive symptoms was in differentiating between the alcoholics and heroin addicts (Table III). The hit rate obtained originally with all 21 variables was 71.2% for correct classification according to alcohol or heroin use, and the restricted analysis with four items only reduced the hit rate to 69.3%. The 1.9% difference indicated that the four items were extremely efficient in assigning the patients to their correct diagnoses.

DISCUSSION

The overall pattern of results supported the contention that alcoholics and heroin addicts may be differentiated by their types of depressive symptomatology. Sense of failure and somatic preoccupation were higher in alcoholics than heroin addicts, and heroin addicts complained of more weight loss and loss of libido than the alcoholics. Three of these specific depressive symptoms, however, may be confounded with the psychoactive properties of alcohol and heroin, respectively. The sense of failure is a cognitive symptom which is unlikely to be a direct product of substance abuse.

A host of physical complications have been associated with alcoholism and the alcoholics’ increased concern with their physical health is warranted. Heroin use has also been related to loss of weight and reduced libido. It is possible that the chemicals merely exacerbated these three physical symptoms of depression in the alcoholics and heroin addicts. Further research needs to address the relationships between the physical effects of the illicit substances and depressive symptomatology. Given the current sample, it is also necessary to determine whether depressive symptomatology will

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differentiate between groups of alcoholics and heroin addicts reflecting different social-economic strata. Note that the prediction of heroin addicts (76% as a group) was better than the prediction of alcoholics (56% as a

group). The results suggest that the sense of failure presented by alcoholics

may be a crucial depressive symptom differentiating alcoholics from heroin addicts. Therapeutic interventions designed to foster self-esteem, dispel guilt feelings and strengthen current achievement may prove to be particul- arly efficacious in helping some alcoholics.

REFERENCES

1 E.X. Freed, Int. J. Addict., 13 (1978) 173. 2 J.E. Hamm, L. Major and G.L. Brown, Am. J. Psychiatry, 136 (1979) 580. 3 R.A. Steer, G.D. Emery and A.T. Beck, J. Clin. Consult. Psychol., 36 (1980) 798. 4 R.A. Steer and J. Schut, Am. J. Psychiatry, 136 (1979) 1463. 5 B.F. Shaw et al., Br. J. Addict., 74 (1979) 295. 6 M.A. Lipson, Am. J. Psychiatry, 136 (1979) 497. 7 R. Cadoret and G. Winokur, Ann. N.Y. Acad. Sci., 233 (1974) 34. 8 R.A. Steer et al., Psychol. Rep., 41 (1977) 1235. 9 A.T. Beck et al., Arch. Gen. Psychiatry, 4 (1961) 561.

10 A.T. Beck et al., Cognitive Therapy of Depreision, Guilford Press, New York, 1979.

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Depressive symptoms differentiating between heroin addicts and alcoholics