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The Severity of Dependence Scale (SDS) as screening test for benzodiazepine dependence: SDS validation study
Abstract
To assess the validity of the Severity of Dependence Scale (SDS) as a screening test to detect benzodiazepine dependence in regular benzodiazepine users.
One hundred regular benzodiazepine users, recruited from neurotic benzodiazepine users attending the Mental Health Outpatient Services of the Canary Islands Health Service, were administered the SDS and responses were compared with the Composite International Diagnostic Interview (CIDI) diagnosis of benzodiazepine dependence. Receiver Operating Characteristic (ROC) analysis was used to determine which cut-off score on SDS allowed the best trade-off between sensitivity and specificity.
SDS was shown to have high diagnostic utility, and a score higher than six on the scale appears to be an appropriate threshold for problematic benzodiazepine use. The SDS had a specificity of 94.2% and a sensitivity of 97.9%, and the area under the curve was of 0.991.
The SDS was found to be a valid brief self-report questionnaire for the assessment of benzodiazepine dependence in patients using benzodiazepines.
... It is easy to understand and can be completed by most users in less than 1 minute [9,17e19]. The SDS, originally designed in English [17], was first used to screen for BZD dependence among regular users [18]. The scale was subsequently translated into many languages [20] and put into widespread use for different illicit drugs across different cultures. ...
... Marital status affected the development of BZD dependence in our study, which is different from the results of most previous studies [9,12,15,23]. The SDS has been a reliable and valid questionnaire when used to assess the degree of dependence on different types of illicit drugs [17,18]. In one study, the SDS was used to screen for BZD dependence among neurotic patients for whom a Compositing International Diagnostic Interview 2.1 diagnosis of BZD dependence had been made. ...
... In one study, the SDS was used to screen for BZD dependence among neurotic patients for whom a Compositing International Diagnostic Interview 2.1 diagnosis of BZD dependence had been made. A cutoff score of 7 or higher on the SDS had high diagnostic utility (AUC Z 0.991), high sensitivity (97.9%), and high specificity (94.2%) [18]. In our study, the SDS [Ch] diagnosis of BZD dependence had the same high diagnostic utility as the SDS and the same cutoff score [18]; however, our results for AUC, sensitivity, and specificity were lower than the previous results for the SDS [18]. ...
The development of an instrument to estimate the incidence, characteristics, and risk factors of benzodiazepine (BZD) dependence broadly in Taiwan is an important task. This study assessed the validity of the Chinese version of the Severity of Dependence Scale (SDS [Ch]) among regular BZD users in Taiwan (n Z 228). A positive correlation was shown between SDS [Ch] and Mini-International Neuropsychiatric Interview diagnosed of BZD dependence. Thirty-six percent of the users received a Mini-International Neuropsychiatric Interview diagnosis of current BZD dependence. The dependent users tended to be divorced/widowed; not schizophrenic ; and have higher SDS [Ch] scores, a longer duration of use, and multiple-BZD use. The SDS [Ch] for BZD dependence was shown to have high diagnostic utility (area under the receiver operating characteristic curve Z 0.779), a sensitivity of 80.5%, and a specificity of 85.7%, with a cutoff point of 7. The findings support that the SDS [Ch] is a valid brief self-reported questionnaire for the assessment of BZD dependence among chronic users in Taiwan.
... The predictive value of the younger age is controversial in the literature. The major part of studies that we have consulted did not confirm this hypothesis (Manthey et al., 2012;de las Cuevas, Sanz, de la Fuente, Padilla, & Berenguer, 2000). However, according to Kan et al. (2004), the younger the age of the patient, the higher the risk of benzodiazepine dependence is. ...
... This could be explained by the predominance of women among dependents and men among nondependents. In fact, the prevalence of smoking is higher in men in Tunisia (Fakhfakh, Hsairi, Maalej, Achour, & Nacef, 2002). By contrast, alcohol use disorder was more prevalent among those who developed benzodiazepine dependence. ...
... The tolerated duration for benzodiazepine intake in patients with anxiety disorders, which can reach 3 months, is longer than it is for those with depression (Guelfi & Rouillon, 2012). Patients with both anxiety disorder and depression might thus be exposed to benzodiazepines for longer periods than those with depression only, which enhances dependence risk (Fakhfakh, Hsairi, Maalej, Achour, & Nacef, 2002) We observed that patients who developed benzodiazepine dependence were more likely to have anxiety disorders than those who did not (Table 2). This difference that we found in the descriptive study was not statistically significant (Table 4). ...
Benzodiazepines may be prescribed to manage anxiety and insomnia in patients with depression. However, as noticed during our daily practice, a considerable proportion of patients treated for depression and receiving benzodiazepines developed a dependence to these medicines. Our aims were to estimate the proportion of patients with depression who develop a benzodiazepine dependence and to identify its correlates. We conducted a comparative study in Razi Hospital's outpatient psychiatry unit (Tunisia). We included patients aged 18 to 65 years who were diagnosed with depression during the first three quarters of 2014. Included patients were prescribed benzodiazepines. Follow-up period was of 2 years. A multivariate analysis was performed to identify dependence-associated factors. We included 54 patients, and 52% developed a benzodiazepine dependence during the follow-up period. Two associated factors were identified: a daily mean benzodiazepine dose of more than 9.5 milligrams of diazepam equivalents prior to taper off (p = .001) and a benzodiazepine taper-off initiated after the fifth week of benzodiazepine intake onset (p = .007). The proportion of patients who developed a benzodiazepine dependence was high. Low doses and time-limited benzodiazepine prescription should be taken into consideration when managing patients with depression in order to prevent dependence.
... Bislang liegen keine detaillierten Publikationen zur Validität von Screeningverfahren bei medikamentenbezogenen Störungen aus Deutschland vor. Auch die internationale Forschungslage ist begrenzt und fokussiert meist auf Patienten mit einer Langzeitverschreibung abhängigkeitserzeugender Medikamente und auf ausschließlich ältere Patienten [16,17]. ...
... Die Severity of Dependence Scale (SDS) wurde ursprünglich von Gossop und Philipps zur Bestimmung des Abhängigkeitsgrades bei Opiatabhängigen entwickelt und später auch bei Heroin, Kokain und Amphetaminen [28] eingesetzt. Der Fragebogen wurde in einer Studie von de las Cuevas [17] als Screeningtest für Benzodiazepinabhängigkeit bei Langzeitanwendern ( > 3 Monate) validiert. Hierbei konnte sich bei einem Cut-off-Wert von 7 Punkten eine Spezifität von 94,2 % und eine Sensitivität von 97,9 % gezeigt werden. ...
... Durch Übersetzung vom Englischen ins Deutsche und Rückübersetzung des gesamten SDS durch hierfür qualifizierte Personen wurde eine für das Setting in einem Allgemeinkrankenhaus erforderliche Ver-sion geschaffen. Zur Maximierung der Sensitivität und Überprüfung der diagnostischen Güte wurde der Cut-off-Wert auf 5 Punkte abgesenkt, da es sich bei den Studien von de las Cuevas [17] und Tsai [29] ...
Zusammenfassung
Ziel Abhängigkeit und Missbrauch von verschreibungspflichtigen Medikamenten sind prävalente Störungen, die durch das Suchthilfesystem kaum erreicht werden. Verfahren zur frühen Erkennung von Betroffenen in medizinischen Settings könnte zu einer Verbesserung der Versorgung beitragen, wobei entsprechende Screeningverfahren unzureichend validiert sind.
Methodik In einer pro-aktiven, unausgelesenen Stichprobe von 6042 konsekutiven Patienten zweier Allgemeinkrankenhäuser in Lübeck wurde ein Screening mittels des Kurzfragebogens zu Medikamentenabhängigkeit und Missbrauch KMM und der Severity of Dependence Scale durchgeführt. Bei Screening-auffälligen Patienten (n=226, Ausschöpfung 55,3%) sowie einer randomisierten Teilstichprobe von 334 Screening-negativen Patienten wurde eine standardisierte klinische Diagnostik medikamentenbezogener Störungen durchgeführt. Für beide Verfahren wurden optimale Cut-off-Werte und die klinische Validität mittels ROC-Kurven bestimmt.
Ergebnisse Von 226 Screening-auffälligen Patienten mit Einnahme abhängigkeitserzeugender Medikamente nach der Anatomical Therapeutical Classification wurde bei 98 Personen eine medikamentenbezogene Störung diagnostiziert. In der Teilstichprobe der Screening-negativen Patienten wurden bei 2 Patienten entsprechende Störungen festgestellt. Bei beiden eingesetzten Screeningverfahren zeigte sich eine gute Sensitivität und Spezifität. Reine Fragebogendaten ohne Prüfung der eingenommenen Medikamente führten jedoch zu hohen Raten falsch-positiver Befunde.
Schlussfolgerung Medikamentenbezogene Störungen können ökonomisch und valide durch Fragebogenverfahren identifiziert werden, wenn in einem zweiten Schritt die genaue Medikation erfasst und eine klinische Diagnostik durchgeführt wird. Die Aussagekraft von Screeningverfahren zu medikamentenbezogenen Störungen ohne fallbezogene klinische Validierung ist eingeschränkt.
... A literature review revealed two studies utilising the severity dependence scale (SDS), a short, five-item, self-report questionnaire that displayed value in assessing dependence in patients using benzodiazepines on a chronic basis. 13,14 De Las Cuevas et al. 13 compared the SDS to the composite diagnostic international interview in 100 chronic benzodiazepine users at an outpatient mental health clinic in the Canary Islands. They found that the SDS, using a score greater than 6, was able to correctly identify 92% of patients who met the criteria for benzodiazepine dependence. ...
... A literature review revealed two studies utilising the severity dependence scale (SDS), a short, five-item, self-report questionnaire that displayed value in assessing dependence in patients using benzodiazepines on a chronic basis. 13,14 De Las Cuevas et al. 13 compared the SDS to the composite diagnostic international interview in 100 chronic benzodiazepine users at an outpatient mental health clinic in the Canary Islands. They found that the SDS, using a score greater than 6, was able to correctly identify 92% of patients who met the criteria for benzodiazepine dependence. ...
... Since the inception of the SDS, studies 13,14,15,16 have utilised it in research for the dependence of various substances. These pre-DSM 5 era-based studies assessed utility of the SDS as a screening tool in assessing dependence as opposed to substance abuse. ...
Background: Benzodiazepines are often used as a part of mental health pharmacological management; however, often when prescribed for extended periods, they increase the risk of benzodiazepine use disorder (BUD). Clinical interviews are at the centre of diagnosing this disorder. However, in addition to clinical assessment a simple, validated questionnaire conducted by any healthcare professional may aid in screening for BUD and referral for further management.
Aim: To compare the accuracy of the severity dependence scale (SDS) as a screening tool for BUD against the standard clinical interviews using the Diagnostic and Statistical Manual of Mental Disorders, edition 5, (DSM 5) checklist amongst benzodiazepine users with primary psychiatric disorders.
Setting: Outpatient psychiatric clinic in South Rand Hospital, Johannesburg, South Africa.
Methods: A cross-sectional study was conducted, once informed consent was attained, looking at demographic and clinical profiles of benzodiazepine users. Clinical interviews were conducted in 81 patients who completed the SDS. In comparing the results of the SDS and clinical interview outcomes, chi-square tests were used to determine an association between categorical variables. A receiver-operating characteristic (ROC) curve was generated in determining the cut-off score in the SDS with the highest sensitivity and specificity.
Results: This study indicated that a cutoff score of greater than or equal to six of the SDS showed 86% sensitivity and 90.3% specificity compared to a diagnosis of BUD made with clinical interview. The only categorical variables of marginal significance (p~0.06) in comparison to a BUD diagnosis were with benzodiazepine type (oxazepam) and longer duration of use (greater than 24 months).
Conclusion: This study identified the SDS as a useful screening tool for BUD with a high sensitivity and specificity compared to interview outcomes. Statistically, correlates were identified between duration and type of benzodiazepine prescribed and BUD suggesting emphasis on these factors when prescribing benzodiazepines.
... In research to date, the psychometric properties of the SDS have been investigated in populations using illicit drugs (14)(15)(16), alcohol (17), and nicotine (18). Optimal cut-off scores on the SDS for probable psychological dependence, when measured against the presence of a diagnosis obtained from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), have been determined for amphetamine (19), cocaine (20,21), benzodiazepines (22), alcohol (23), and cannabis (24). The scale has previously been used to determine the level of probable codeine dependence amongst adults in Australia reporting use of "over-the-counter" codeine (25). ...
... Previous studies have determined a cut-off point on the SDS that discriminates between the presence and absence of a DSM-5 diagnosis for substance dependence suggesting its implementation and usefulness in clinical settings. These studies found a SDS score of 3 or above optimal for characterizing a DSM-5 diagnosis of alcohol dependence (23), whereas a cut-off score of 7 was found to be the appropriate threshold for dependence to benzodiazepines (22). In this study, several factors relating to aberrant codeine use were associated with probable codeine dependence when using a cut-off score of 5. Research with people attending specialized drug addiction treatment for codeine would enable a comparison between SDS scores and DSM-5 diagnosis, possibly enabling its use in clinical settings as a quick way of determining possible psychological dependence on codeine. ...
Objective: Investigate the psychometric properties of the Severity of Dependence Scale (SDS) for codeine and its association with aberrant codeine related behaviors.
Design: A voluntary and uncompensated cross-sectional online survey.
Setting: Online population (≥18 years).
Respondents: Two hundred and eighty-six respondents (66% women) who had used codeine containing medicines in the last 3 months and were living in the UK.
Results: Of the respondents (mean age = 35.4 years, SD = 12.5), more than half were employed. Only 3.5% respondents reported no income. The majority of respondents (45.1%) primarily obtained prescription-only codeine from a consultation with a health professional, whilst 40.9% mainly purchased “over-the-counter” codeine containing medicines in a pharmacy without a medical prescription. Principal component analysis indicated a single factor solution accounting for 75% of the variance. Factor loadings ranged from 0.83 to 0.89. Cronbach's Alpha was high (α = 0.92). Several behaviors relating to codeine use were found to significantly predict probable codeine dependence. These included: daily codeine use in the last 3 months (OR = 66.89, 95% CI = 15.8–283.18); tolerance to codeine (OR = 32.14, 95% CI = 13.82–74.75); problems with role responsibility due to intoxication (OR = 9.89, 95% CI = 4.95–19.78); having sought advice on the internet to manage codeine use (OR = 9.56, 95% CI = 4.5–20.31); history of alcohol or drug treatment (OR = 3.73, 95% CI = 1.88–7.43).
Conclusions: The SDS was acceptable and feasible to use to assess probable psychological codeine dependence in an online sample of people using codeine containing medicines. SDS scores were associated with behaviors known to be indicators of codeine dependence. Studies are needed in well-defined populations of people who use codeine to test the different aspects of psychometry of the scale compared against “gold standard” criterion [a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)].
... Drug types and combinations, amount/dose, administration route, and withdrawal phases were examined. Benzodiazepine dependence was assessed via the Severity of Dependence Scale (SDS; Gossop & Darke, 1995), with the cutoff score of 7 or more (de las Cuevas et al., 2000). Finally, the Criminality Index from the Opiate Treatment Index (OTI; Darke et al., 1992) was used to measure criminal behavior (property crime, drug dealing, fraud, and violent crime) in the month prior to the index offence. ...
... In addition, no correction was made to protect against type 1 error. Data collection relied on uncorroborated retrospective self-report, a proportion of the sample neglected to provide crime information (i.e., nonspecified "other" crime), and the reliability of the TLFB over the 6-month reporting period was not assessed (Davis et al., 2014;Sacks et al., 2003). Alternative interpretations need also be considered that dependence to benzodiazepines may develop via attempts to manage preexisting violent tendencies and difficulty excluding whether reported aggression occurred during benzodiazepine withdrawal (Votava et al., 2001). ...
Objective: To explore the relationship between benzodiazepine use and violent crime in a sample of community-based offenders. Methods: Participants were recruited via drug diversion and treatment programs in Melbourne, Australia. Data regarding benzodiazepine and other substance use, mental health, personality characteristics, and crime involvement were collected through semistructured interviews conducted in 2011. Participants (n = 82, 79.3% male) were 21–56 years old, predominantly Australian-born (89%), with 14.6% identifying as Aboriginal or Torres Strait Islanders. Eligibility criteria were having been charged with a criminal offence in the previous six months and at least monthly benzodiazepine use. Group differences between violent (n = 11) and nonviolent offenders were assessed via independent samples t-tests (two-tailed) and nonparametric tests. Results: Individuals charged with violent index offences were significantly more likely to use higher average doses of alprazolam (p = 0.040) and exhibit benzodiazepine dependence (p = 0.037) as well as report high levels of sensation seeking, prior violence, and the diagnoses of depression and personality disorder than individuals charged with nonviolent index offences. Conclusions: The findings suggest the existence of a complex dynamic between mental health and violent offending that may be influenced by benzodiazepine use, in particular alprazolam. A core implication of these preliminary findings includes attending to the interpersonal skills and adaptive coping resources of violent offenders.
... Psychological dependence features include chewers urge to get their amount of khat on the expenses of their vital needs like food and mood changes during and after chewing [9,20,21,[27][28][29]. The Severity of Dependence Scale (SDS) developed by Gossop et al. [30] was used to evaluate psychological dependence to many abused drugs through collecting data about the dependence features [30][31][32][33]. SDS was validated and employed by Kassim and her colleagues to assess the psychological dependence of khat chewing among Yemeni population living in UK [18]. ...
. Khat chewing is highly prevalent in Africa, Yemen and Jazan region, southwest of Saudi Arabia. Most of Jazani Khat chewers consider khat session as a social activity and do not consider khat dependency. The aim of this study was to explore khat dependency and its relationship with the psychophysical symptoms among chewers.
Methods
. Cross-sectional study on seventy Saudi male khat chewers living in Jazan area. Psychological dependence to khat chewing was evaluated using the Severity of Dependency Scale (SDS). The participants filled in a self-administrated assisted structured questionnaire designed to collect data about their medical history, neurological symptoms, and their chewing behavior.
Results
. Half (52.2%) of khat chewers showed psychological dependency. Those having longer khat sessions (≥6 hours) were more liable for dependency. Physical and psychological symptoms were more prevalent among khat dependent chewers.
Conclusions
. khat has a psychological dependence effect that can be measured by the SDS, even in low doses and with irregular use. SDS scale is a useful tool to expect the burden of either physical or psychological symptoms on khat chewers.
... In these cases, research with this instrument has established cut-off points for determining dependence on the following substances. For opiates, the cut-off is 5 (Iraurgi, González, Lozano, Landabaso, & Jiménez, 2010); for alcohol, 3 (Lawrinson, Copeland, Gerber, & Gilmour, 2007); for amphetamines, 4 (Topp & Mattick, 1997); for cocaine, 3 (Kaye & Darke, 2002); for cannabis, 3 (Swift, Copeland, & Hall, 1998) and 4 (Martin, Copeland, Gates, & Gilmour, 2006;Pol et al., 2013); for benzodiazepines, 7 (De las Cuevas, Sanz, De la Fuente, Padilla, & Berenguer, 2000;Tsai et al., 2012); and for medication overuse for chronic headache, 4 in men and 5 in women (Lundqvist, Benth, Grande, Aaseth, & Russell, 2011). ...
Background and aims:
There is a lack of instruments for measuring ketamine substance use disorders. The aims were (i) to estimate the reliability and provide evidence of validity of the Severity of Dependence Scale (SDS) in a sample of recreational users, and (ii) propose a cut-off point to determine the presence of dependence.
Methods:
We conducted a web-based cross-sectional survey with recreational users who accessed webs related to recreational drug use and harm reduction. 264 recreational ketamine users who had taken it in the past month participated in the study. The Spanish version of the SDS was used. Information on ketamine use-related problems and ketamine use patterns was also collected.
Results:
The reliability estimation calculated by the Cronbach's alpha coefficient was 0.776. SDS showed evidence of convergent validity based on relationships with other variables. Two comparisons were made in this study to analyze the Receiver Operating Characteristic Curve. For frequency of use in the last month the area under curve (AUC) was 0.835 (CI=0.775-0.895) with optimal discrimination at an SDS score of 3. For having been in treatment for decreasing or quitting ketamine use the AUC was 0.902 (CI=0.840-0.963) and the cut-off point was 4. Confirmatory factor analysis showed a one-dimensional structure when Items 3 and 4 were correlated.
Conclusions:
This study has provided evidence of reliability and validity of the ketamine version of the SDS for recreational users. Considering that ketamine use is linked to young people and its strong potential for causing serious impairment, a cut-off of 3 is proposed as indicative of dependence.
... Moreover, it has been demonstrated that the scale can be applied to amphetamine use in place of more lengthy instruments such as the CIDI Composite International Diagnostic Interview) with little loss of diagnostic power. A cut-off score on the SDS has been evaluated specifically for amphetamine dependence (Topp & Mattick 1997), and also for dependence on alcohol, cannabis, heroin and benzodiazepines and cocaine (de las Cuevas et al, 2000, Kaye & Darke, 2002, Lawrinson et al, 2007, Martin, et al, 2006, Swift, Copeland & Hall, 1998. ...
The Second Amphetamines in Queensland Study (AIQ2) is a repeat of the original study (AIQ1), which was conducted in 2002 to inform responses to the emerging issue of amphetamine-related harm in Queensland. The current study updates information gathered from AIQ1 and assesses some of the market and population-level changes that have occurred. Anecdotal and routine information from health and law enforcement agencies, in addition to data from sentinel sources such as the Illicit Drug Reporting System, suggest that there have been some significant changes during this decade. This report provides a detailed examination of these changes. AIQ2 also focuses on specific issues not included in AIQ1, such as estimates of the prevalence of depression and psychosis among amphetamine users. In addition, similar to the first study, peer education initiatives for amphetamines users were an integral part of the AIQ2 fieldwork.
... A short form of the Alcohol Use Disorders Identification Test (AUDIT-C) was included; a cutoff score of 5 was used to indicate alcohol-related problems (Bush et al., 1998). The Severity of Dependence Scale (SDS) was used to assess severity of benzodiazepine dependence; a cut-off score of 7 was used to indicate possible dependence (Cuevas et al., 2000). ...
Objective:
The aims were to determine: (i) quantity and frequency of same-day use of opioids with benzodiazepines and/or alcohol amongst people who regularly tamper with pharmaceutical opioids; and (ii) socio-demographic, mental health, harms and treatment profile associated with same-day use of high doses.
Method:
The cohort (n=437) completed a retrospective 7-day diary detailing opioid, benzodiazepine, and alcohol intake. Oral morphine equivalent (OME) units and diazepam equivalent units (DEU) were calculated, with >200mg OME, >40mg DEU and >4 standard alcoholic drinks (each 10g alcohol) considered a "high dose".
Results:
One-half (47%) exclusively consumed opioids without benzodiazepines/alcohol; 26% had days of opioid use with and without benzodiazepines/alcohol; and 26% always used opioids and benzodiazepines/alcohol. Same-day use of opioids with benzodiazepines/alcohol typically occurred on 1-3days in the past week. Six in ten (61%) participants reported high dose opioid use on at least one day; one in five (20%) reported high dose opioid and high dose benzodiazepine/alcohol use on at least one day. The latter group were more likely to use prescribed opioid substitution therapy, often alongside diverted pharmaceutical opioids. Socio-demographic and clinical profiles did not vary according to high dose opioid, alcohol and benzodiazepine use, and there was no association with harms.
Conclusions:
Same-day use of opioids with benzodiazepines/alcohol, and high dose combinations, are common amongst people who tamper with pharmaceutical opioids. Assessment of concomitant benzodiazepine/alcohol use during opioid therapy, implementation of real-time prescription monitoring systems, and research to clarify upper safe limits for polydrug depressant use, are potential implications.
... The Severity of Dependence Scale (SDS) was used as a brief screener for possible codeine dependence. This has been validated with a range of substances, including heroin, cocaine, amphetamines [38][39][40], benzodiazepines [41], cocaine [42], cannabis [43], and alcohol [44]. In addition to a range of substances, the SDS has also been validated with problematic analgesic use (including combination products containing codeine) [45] where a cutoff of 5 or more demonstrated reasonable sensitivity (72.3%) and specificity (78.6%) for identifying individuals who may be problematic users of analgesics [45,46]. ...
Background:
On February 1, 2018, Australia rescheduled codeine to a prescription-only medication. Many concerns were associated with this change, including increased financial costs, reduced service accessibility, the potential for poorer pain management, and a decline in physical and mental health if codeine could not be accessed. In the research literature, there is limited knowledge about the long-term consequences of rescheduling pharmaceutical opioids and, as Australia has followed many countries in implementing a restriction on codeine, further study of these consequences is critical.
Objective:
The goal of this study was to examine the impact of rescheduling codeine from an over-the-counter (OTC) product to a prescription-only medicine on the primary measures of codeine use and dependence in a prospective cohort of people who are frequent consumers of OTC codeine. Secondary measures included pain and self-efficacy, health service use, and mental health.
Methods:
The Codeine Cohort study aimed to recruit 300 participants in Australia who regularly (at least a few times per week for the past 6 months) used OTC codeine. Using an online survey, participants were followed up at three time points (February 2018, June 2018, and February 2019) after codeine was rescheduled.
Results:
All four waves of data collection are complete, with the final round of data collection finalized in August 2019. Data analyses are yet to be completed. Information on demographics, codeine use and dependence, physical and mental health, medication use, and health service use will be analyzed using mixed models.
Conclusions:
Results of this study will provide insight into the effectiveness of regulatory restriction in curtailing nonmedical use of and harms associated with codeine. Additionally, results will explore positive and negative outcomes of codeine rescheduling for individual patients, which informs health professionals who support patients who use codeine and further community education.
International registered report identifier (irrid):
DERR1-10.2196/15540.
... All benzodiazepines have the potential to create addiction on the term that those with short duration effect cause addiction more frequently and faster (primarily midazolam, lorazepam). In 15-44% of people on long-term (4-6 weeks) taking benzodiazepines, will be present a moderate to severe withdrawal syndrome aft er abrupt discontinuation of benzodiazepines [2]. It is a serious medical condition with polymorphic symptoms that require drug treatment. ...
Background: Today in the world and in Serbia is growing number of people who are addicted to benzodiazepine. A particular problem is the process of detoxification and treatment of benzodiazepine withdrawal syndrome due to a recurrence of symptoms of anxiety disorder, availability of benzodiazepines, falling motivation. Standard procedures have often proved unsuccessful and the last decade, and the search for new protocols, including the flumazenil, benzodiazepine receptor antagonist, is actualized. Case report: The patient aged 48 years was admitted to the specialist psychiatric clinic, for treatment of benzodiazepine addiction. Anxiety disorder was diagnosed since adolescence perennial addiction on benzodiazepines and the initial withdrawal syndrome. Former motivated topical treatments for detoxification were unsuccessful. The presence of dual diagnosis, persistence of both disorders in perennial cycle, treatment resistance and actual motivation contributed to the decision to opt rapid detoxification from benzodiazepines by flumazenil application protocol, for hospital treatment by adjuvant therapy with lamotrigine. After discharge from hospital in stable condition it was with no signs of withdrawal syndrome and a rebound of anxiety symptoms. Lamotrigine medication continued including CBT, held during the one-year abstinence monitoring, with sufficient social functionality. Discussion: The efficacy and safety of flumazenil in the treatment of benzodiazepine withdrawal syndrome was investigated in numerous clinical trials, and the mechanism of action is complex, from the benzodiazepine antagonist to inverse agonist in certain circumstances, as well as 'up-regulation' receptors, which together leads to a reduction in symptoms of abstinence syndrome and anxiety in the longer term after treatment, thereby acting favorably to the adherence and remission. Conclusions: Flumazenil protocol is an efficient method in the treatment of the benzodiazepine withdrawal syndrome. Given the existence of certain concerns and relatively little experience in this procedure, it is necessary to define further all aspects of the procedure.
... 19 It consists of five questions, scored from 0 to 3, and can be used to measure the degree of dependence on a range of substances, 19,20 including medicines. 21 We used a cut-off score of !5 as this has previously been used to determine codeine dependence. 22 Respondents answered all the required scale items. ...
Background:
Codeine misuse and dependence poses a clinical and public health challenge. However, little is known about dependence and treatment needs in the UK and Ireland.
Aim:
To characterise codeine use, dependence, and help-seeking behaviour.
Design:
An online cross-sectional survey advertised on Facebook, Twitter, health and drug websites and e-mail circulars.
Methods:
The survey collected data on demographics and codeine use amongst adults from the UK and Ireland. The Severity of Dependence Scale measured the level of codeine dependence.
Results:
The sample of 316 respondents had a mean age of 35.3 years (SD = 12.3) and 67% were women. Of the 316 respondents, 54 scored ≥5 on the Severity of Dependence Scale indicating codeine dependence (17.1%). Our study found that codeine dependence is a problem with both prescribed and 'over-the-counter' codeine. Codeine dependence was associated with daily use of codeine, faking or exaggerating symptoms to get a prescription for codeine and 'pharmacy shopping' (P < 0.01). A higher number of respondents had sought advice on the Internet (12%) rather than from their general medical practitioner (GP) (5.4%). Less than 1% of respondents had sought advice from a pharmacist.
Conclusions:
Codeine dependent users were more likely to seek help on the Internet to control their use of codeine than from a GP, which may indicate a potential for greater specialised addiction treatment demand through increased identification and referrals in primary care.
... This cut-off score has been previously reported in other literature (De Las Cuevas, Sanz, De La Fuente, Padilla, & Berenguer, 2000;Topp & Mattick, 1997); however, the establishment of an optimal diagnostic cut-off with a correctional population is necessary so that the SDS can be formally considered for clinical decision-making. ...
Between 70% to 80% of Correctional Service Canada’s (CSC) general offender population and over 90% of its Aboriginal offender population has an identified substance abuse problem requiring intervention. Ensuring that these offenders receive the most effective treatment is a major challenge that is best addressed through the application of assessments that are shown to be reliable, accurate, and useful for client-treatment matching and correctional planning. Aim. The main objective of the study was to establish the Severity of Dependence Scale (SDS) (Gossop et al. 1995) as a suitable measure for client-treatment matching, and as a predictor of recidivism and relapse to substance use. Setting. The SDS and the Drug Abuse Screening Test (DAST) (Skinner, 1982) were administered to a sample of 3350 adult, male inmates from CSC between 2002 and 2007. A total of 1667 inmates were eventually released from custody and available for 24 months of follow-up. Measurements. Cronbach’s coefficient alpha provided a measure of internal consistency (reliability), and canonical correlation analysis quantified the dimensional relationship between the two instruments. With DAST as the reference standard, Receiver Operating Characteristics (ROC) analyses established the optimal cut-off score for a classification of psychological drug dependence on the SDS. A number of multivariable logistic regression models uncovered the dimensions of the classification, while a series of Cox proportional hazards models examined SDS’s ability to predict the rates of revocation and relapse to substance abuse over a maximum of 24 months of follow-up into the community. Findings. Large Cronbach’s coefficient alpha values confirmed the internal consistency of both the DAST and SDS. The canonical correlation analysis revealed linear combinations of DAST and SDS items that were highly correlated along a single dimension that closely approximated the dependence syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders-IV. The results from the logistic regression and Receiver Operating Characteristics (ROC) analyses underscored the strong relationship between DAST’s classification of drug dependence and the SDS. The cut-off value of ≥ 6 for a classification of psychological drug dependence produced the best trade-off between sensitivity and specificity. The individual logistic regression models and the significant unconditional associations between indicators within a number of life domains and psychological drug dependence uncovered a host of deficits that are important for client-treatment matching and correctional planning. The SDS was also predictive of post-release outcomes. After adjusting for the effects of other predictors within a series of Cox proportional hazards models, offenders who were classified as psychologically drug dependent had higher hazards of revocation and relapse to substance abuse. However, exposure to the high intensity program and community-based maintenance reduced the hazard of revocation and relapse to substance. Conclusions. The SDS was a reliable measure of psychological drug dependence, and useful for differentiating offenders for treatment and for predicting post-release outcomes. The findings underscore the importance of accurately matching offender criminogenic need to appropriate levels of service delivery, and reinforce the importance of community aftercare in mitigating the risk of recidivism and relapse to substance abuse.
... It is reasonable to assume that both mechanisms may contribute. The SDS (Gossop et al., 1995) is a much used instrument which has previously been validated for behavioral dependence among patients overusing both alcohol (Lawrinson et al., 2007), several illegal and legal drugs (Gossop et al., 1995;Topp and Mattick, 1997;De Las Cuevas et al., 2000;Kaye and Darke, 2002;Martin et al., 2006). The definition of substance dependence used here is from the DSM-IV definitions based on a structural diagnostic interview (MINI) (American Psychiatric Association, 2000;Sheehan et al., 1998). ...
Background and Aims
Medication-overuse headache (MOH) is a common chronic headache caused by overuse of headache analgesics. It has similarities with substance dependence disorders. The treatment of choice for MOH is withdrawal of the offending analgesics. Behavioural brief intervention treatment using methods adapted from substance misuse settings is effective. Here we investigate the severity of analgesics dependence in MOH using the Severity of dependence scale (SDS), validate the SDS score against formal substance dependence diagnosis based on the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV) and examine whether the SDS predicts successful withdrawal.
Methods
Representative recruitment from the general population; 60 MOH patients, 15 chronic
headache patients without medication overuse and 25 population controls. Headaches were diagnosed using the International Classification of Headache Disorders, medication use was assessed and substance dependence classified according to the DSM-IV. The SDS was scored by interviewers blinded to patient group. Descriptive statistics were used and validity of the SDS score assessed against a substance dependence diagnosis using ROC analysis.
Results
Sixty-two % of MOH patients overused simple analgesics, 38% centrally acting analgesics
(codeine, opiates, triptans). Fifty % of MOH patients were classified as DSM-IV substance
dependent. Centrally active medication and high SDS scores were associated with higher
proportions of dependence. ROC analysis showed SDS scores accurately identified
dependence (area under curve 88%). Lower SDS scores were associated with successful
withdrawal (p=0.004).
Conclusions
MOH has characteristics of substance dependence which should be taken into account when choosing treatment strategy.
... Repeated and persistent stress [3], irritants, chronic diseases, and specific life stages (e.g., the perinatal period) [4] may lead to the development of anxiety disorders, which causes emotional and financial burdens to the patients. Common anxiolytic drugs, such as benzodiazepines, which are the most extensively studied at present, have side effects, such as sedation, memory disorders, tolerance, and withdrawal symptoms [5]. Therefore, it is necessary to develop alternative drug treatment strategies. ...
Anxiety disorder impacts the quality of life of the patients. The 95% ethanol extract of rhizomes and roots of Valeriana jatamansi Jones (Zhi zhu xiang, ZZX) has previously been shown to be effective for the treatment of anxiety disorder. In this study, the dose ratio of each component of the anxiolytic compounds group (ACG) in a 95% ethanol extract of ZZX was optimized by a uniform design experiment and mathematical modeling. The anxiolytic effect of ACG was verified by behavioral experiments and biochemical index measurement. Network pharmacology was used to determine potential action targets, as well as predict biological processes and signaling pathways, which were then verified by molecular docking analysis. Metabolomics was then used to screen and analyze metabolites in the rat hippocampus before and after the administration of ZZX-ACG. Finally, the results of metabolomics and network pharmacology were integrated to clarify the anti-anxiety mechanism of the ACG. The optimal dose ratio of ACG in 95% ethanol extract of ZZX was obtained, and our results suggest that ACG may regulate ALB, AKT1, PTGS2, CYP3A4, ESR1, CASP3, CYP2B6, EGFR, SRC, MMP9, IGF1, and MAPK8, as well as the prolactin signaling pathway, estrogen signaling pathway, and arachidonic acid metabolism pathway, thus affecting the brain neurotransmitters and HPA axis hormone levels to play an anxiolytic role, directly or indirectly.
... The SDS ( Gossop et al. 1995) was developed to provide a short, easily-administered measure of an individual's per- ceived level of dependence on alcohol and illicit drugs ( Gossop et al. 1995). It has been found to have high internal consistency and strong construct and concurrent validity across a range of populations, including those experiencing schizophrenia and psychosis (Hides et al. 2007a); heroin, cocaine, and amphetamine addictions ( Gossop et al. 1995); and misuse of prescription medications (de las Cuevas et al. (2000). The scale is designed to be easily understood, and can be completed, in most cases, in under 1 min. ...
Addressing the psychological distress of individuals experiencing substance use disorders has too often been relegated to the ‘too hard basket’, leaving those affected with little choice but to receive treatments aimed solely at addressing their drug and alcohol issues. Conversely, individuals receiving support for psychological issues are often underdiagnosed with regards to any comorbid substance misuse problems. In fact, to date, no definitive treatment model exists that gives equal focus to the treatment of both psychological well-being and substance-related addictions. This is not to suggest, however, that existing treatment programmes for substance misuse are not impacting positively on clients’ mental health, rather that further research is needed in order to determine what it is that is supporting such improvements. The aim of this study, therefore, was to address this imbalance by examining the correlation between substance dependence and psychological well-being. Using a descriptive correlation design, the Severity of Dependence and Kessler 10 scales were administered to 37 inpatient and outpatient clients at a rural drug and alcohol rehabilitation service, at intake and 2 months into treatment. Data were analysed using descriptive statistics and paired-samples t-tests. Positive correlative factors of improvement between substance dependence and psychological well-being were found for both groups. In light of these findings, the authors recommend that future research be undertaken to investigate the causal factors for this correlation.
... Withdrawal symptoms are manifest when the BZD is reduced in dosage or discontinued. The actual clinical problem is their unpleasant nature [11], their severity [15], their duration [16], and their resistance to treatment. Table 3 sets out the most common symptoms although a very wide range has been described. ...
The large class of CNS-depressant medications—the benzodiazepines—have been extensively used for over 50 years, anxiety disorders being one of the main indications. A substantial proportion (perhaps up to 20–30 %) of long-term users becomes physically dependent on them. Problems with their use became manifest, and dependence, withdrawal difficulties and abuse were documented by the 1980s. Many such users experience physical and psychological withdrawal symptoms on attempted cessation and may develop clinically troublesome syndromes even during slow tapering. Few studies have been conducted to establish the optimal withdrawal schedules. The usual management comprises slow withdrawal over weeks or months together with psychotherapy of various modalities. Pharmacological aids include antidepressants such as the SSRIs especially if depressive symptoms supervene. Other pharmacological agents such as the benzodiazepine antagonist, flumazenil, and the hormonal agent, melatonin, remain largely experimental. The purpose of this review is to analyse the evidence for the efficacy of the usual withdrawal regimes and the newer agents. It is concluded that little evidence exists outside the usual principles of drug withdrawal but there are some promising leads.
... The Severity of Dependence Scale (SDS) is another widely used tool that can be adapted for and used to measure dependence in various substances including opioids [25]. Although it has been validated as a dependence measure for alcohol, benozodiazepine, cocaine, amphetamines, cannabis, etc. [26][27][28][29][30][31], it has not been specifically validated for prescription opioids. Further, as the SDS was developed to assess illicit opioid dependence, the questions center only on aspects of illicit substance use and do not collect information that is salient to dependence in the context of therapeutic use, such as escalating doses and associated adverse effects. ...
Objective:
To develop a short, patient-administered screening tool that will allow for earlier assessment of prescription opioid dependence (often referred to as addiction) in primary care settings.
Design and setting:
Cross-sectional analysis (N = 1,134) from the two-year time point of the Pain and Opioids IN Treatment (POINT) cohort was used in the scale development.
Subjects:
Participants who completed two-year interviews in the POINT study, a prospective cohort study that followed people with chronic noncancer pain over a five-year period, and who were prescribed strong opioids for a minimum of six weeks at baseline.
Methods:
An advisory committee provided advice on wording and content for screening in primary care settings. Univariate logistic regression identified individual items that were significantly associated with meeting ICD-11 criteria for prescription opioid dependence. Exploratory and confirmatory factor analysis (EFA and CFA) were conducted, and items were reduced to identify a small item set that were discriminative and shared a simple underlying structure.
Results:
Sixty-four variables associated with ICD-11 criteria for prescription opioid dependence were initially identified. Four rounds of EFA were performed, resulting in five items remaining. CFA identified two possible four-item combinations, with the final combination chosen based on greater item endorsement and the results of goodness-of-fit indices.
Conclusions:
Addressing prescription opioid dependence is an important part of the global public health challenge surrounding rising opioid-related harm. This study addresses an important initial requisite step to develop a brief screening tool. Further studies are required to validate the tool in clinical settings.
... Benzodiazepine substance use disorder can be diagnosed using DSM-5 criteria, 9 but the Severity Dependence Scale is a simple screening tool validated for use in the community. 10 Some patients prescribed benzodiazepines may have aberrant drugrelated behaviours, ranging from double dosing to selling medicines illicitly or injecting them. Systems limitations in prescription monitoring in Australia reduce our ability to identify 'doctor shopping' so the Introduction Despite a modest decrease in the annual number of benzodiazepine prescriptions dispensed, the current level of prescribing probably represents significant overuse. ...
There are well-recognised harms from long-term use of benzodiazepines. These include dependency, cognitive decline and falls. It is important to prevent and recognise benzodiazepine dependence. A thorough risk assessment guides optimal management and the necessity for referral. The management of dependence involves either gradual benzodiazepine withdrawal or maintenance treatment. Prescribing interventions, substitution, psychotherapies and pharmacotherapies can all contribute. Unless the patient is elderly, it is helpful to switch to a long-acting benzodiazepine in both withdrawal and maintenance therapy. The dose should be gradually reduced over weeks to lower the risk of seizures. Harms from drugs such as zopiclone and zolpidem are less well characterised. Dependence is managed in the same manner as benzodiazepine dependence. © 2015, Australian Government Publishing Service. All rights reserved.
... The SDS is a brief five-item scale that measures an individual's self-reported level of psychological dependence for a nominated substance (Gossop, Griffiths, Powis, & Strang, 1992;Gossop et al., 1995). The SDS was developed initially for measuring the dependence of opioids; however, over time it has been validated to measure dependence on other substances including amphetamines, cannabis, cocaine, alcohol, and benzodiazepines (Cuevas, Sanz, Fuente, Padilla, & Berenguer, 2000;Gossop et al., 1995;Lawrinson, Copeland, Gerber, & Gilmour, 2007;Swift, Hall, & Copeland, 1998;Topp & Mattick, 1997). Higher scores on the SDS indicate greater severity of multiple psychological symptoms of substance dependence, including frequency of use as well as impaired control, preoccupation and anxiety about ongoing use. ...
Aims
To examine whether participation in the HIPUs was associated with measurable change in a range of dynamic risk factors that were the targets of intervention.
Methods
The sample included offenders who had commenced or completed participation in the HIPUs and were administered a series of psychometric measures before (N=833) and after completion of the program (N=448). Within-treatment change was calculated at the group level using average simple differences and at the individual level using clinically significant change analyses.
Results
At the time of entering the HIPUs, the most prevalent assessed domains of dynamic risk among participants were related to substance use, anger and impulsiveness. On average, participants showed significant within-treatment change in the expected direction of improvement on almost all measures. Clinically significant change analysis showed that an average of one in five participants who met statistical definitions for having 'dysfunctional' scores on a measure at pre-treatment were classified as 'recovered' at post-treatment. An average of 15% of participants showed statistically significant improvement irrespective of their pre-treatment functioning. Participants most commonly reported improvement in anger-related domains of risk.
Conclusion
Within-treatment change analyses provide preliminary evidence that participation in the HIPUs is associated with improvement in a number of dynamic risk factors. This study also contributes to our understanding of the dynamic risk profiles of short-sentenced offenders such as those entering the HIPUs.
... 21 The new diagnosis requires that at least two of the following criteria have occurred within a 12-month period (the disorder is mild if two to three criteria are met, moderate if four to five are present, and severe with six or more): ■ Continuing to use a barbiturate, benzodiazepine, or other sedative-hypnotic, despite negative personal consequences ■ Repeated inability to carry out major functions at work, school, or home on account of use ■ Recurrent use in physically hazardous situations ■ Continued use despite recurrent or persistent social or interpersonal problems caused or made worse by use ■ Tolerance, as manifested by needing a markedly increased dose to achieve intoxication or desired effect, or by markedly diminished effect with continued use of the same amount ■ Withdrawal with the characteristic syndrome or use of the drug to avoid withdrawal ■ Use of more of the drug or use for a longer period than intended ■ Persistent desire to cut down use or unsuccessful attempts to control use ■ Spending a lot of time obtaining or using the substance or recovering from use ■ Stopping or reducing important occupational, social, or recreational activities because of use ■ Craving or strong desire to use The Severity of Dependence Scale (SDS) was created to provide a short and easily administered self-report scale to measure the degree of dependence for different types of drugs. 22 The SDS contains five items related to the psychological components of dependence. A score above 6 indicates dependence. ...
... Specify if: In early remission: After full criteria for sedative, hypnotic or anxiolytic use disorder were previously met, none of the criteria for sedative, hypnotic or anxiolytic use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, "Craving, or a strong desire or urge to use the sedative, hypnotic or anxiolytic," may be met) In sustained remission: After full criteria for sedative, hypnotic or anxiolytic use disorder were previously met, none of the criteria for sedative, hypnotic or anxiolytic use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, "Craving, or a strong desire or urge to use the sedative, hypnotic or anxiolytic," may be met) developed to measure the severity of dependence (Cuevas et al., 2000). ...
Objectives
A clear definition of what we understand of high-dose misuse or of a ‘markedly increased dose’ (as stated by the DSM-5) is important and past definitions may be inadequate. The aim of this review is to describe the different definitions used and to test these definitions for their accuracy.
Methods
A narrative PubMed literature review was conducted based on articles published between 1 January 1990 and 31 December 2020 describing benzodiazepines (in MeSH Terms or MeSH Major Topic) and high-dose (or high-dosage). Specific definitions were applied to a population sample to show how definitions affect high-dose benzodiazepine prevalence.
Results
Multiples of an equivalent-diazepam dose or of the World Health Organization ‘defined daily dosage’ were used more frequently than the overstep of the recommended maximum therapeutic dosage as a cut-off point.
Conclusion
High-dose use is rare but the prevalence in the general population varies among studies, mainly due to different definitions, making both clinical and epidemiological comparisons between studies difficult. Defining a high-dose user as a person who takes at least a higher dose than the maximum usual therapeutic dose over a defined period of time therefore appears to be clinically more consistent.
... Psychological dependence features include chewers urge to get their amount of khat on the expenses of their vital needs like food and mood changes during and after chewing [9,20,21,[27][28][29]. The Severity of Dependence Scale (SDS) developed by Gossop et al. [30] was used to evaluate psychological dependence to many abused drugs through collecting data about the dependence features [30][31][32][33]. SDS was validated and employed by Kassim and her colleagues to assess the psychological dependence of khat chewing among Yemeni population living in UK [18]. ...
... Diagnosis of benzodiazepine use disorder is based on the DSM-5 criteria. The Severity of Dependence Scale (SDS) is a validated screening tool that can be used to detect not only dependence on benzodiazepines but also opioids and several other illicit substances [50][51][52]. This is a 5 item questionnaire scored from 0 to 3 on each question and a cutoff of 7 is an increased risk for benzodiazepine dependence. ...
Substance use disorder prevalence in older adults is increasing as the baby boom generation ages. Of the different substances with concern for misuse and use disorder, alcohol, prescription drugs and illicit drugs are the leading causes. High risk drinking and alcohol use disorder is the leading substance use disorder in older adults. Prescription drug misuse and use disorder in older adults is the second leading cause for substance use disorder and most commonly involves prescription opioids and benzodiazepines. Illicit drug use in older adults is also increasing. Substance use disorders are difficult to recognize in older adults due to medical comorbidity, neurocognitive impairment and functional decline. Older adults are also more susceptible to drug effects due to decreased hepatic and renal clearance of the substances. Older adults should be screened and assessed for substance use disorders, and when diagnosed, non-pharmacologic as well as pharmacologic intervention should be performed.
... [9][10][11][12][13] More recently, with the acceptance of the biopsychosocial model of dependence, it has been shown that physical signs are not sufficient measures of dependence and that the psychological and social dimensions are also prevalent in the population of benzodiazepine users. 14 Therefore, self-report instruments that also consider the psychosocial aspects of dependence, [15][16][17] or craving 18 were developed. Most of these questionnaires left aside withdrawal aspects and have not been validated in Brazil, except for the Severity of Dependence Scale, which is not specific to hypnotics. ...
Objective
To assess psychometric properties of the Benzodiazepine Dependence Self-Report Questionnaire – Portuguese Version (BENDEP-SRQ-PV) in a sample of Brazilian chronic hypnotic users.
Methods
One hundred and seventy-nine chronic hypnotic users (benzodiazepines and Z-drugs) were recruited, attended a psychiatric evaluation, and answered the BENDEP-SRQ-PV. Factor structure, reliability, and influence of covariates (dependence diagnosis and type of drug consumed) were assessed in a structural equation modelling environment. Discrimination was assessed with receiver operating characteristic (ROC) plots and stability with the test-retest method.
Results
Participants, mostly women (91.6%), aged 51 to 64 years old, had been using hypnotics for an average of 34.8 months, with a mean defined daily dose of 0.72. Psychometric analysis demonstrated construct and criterion validity, reliability, and response stability. The factor structure was maintained as originally proposed: problematic use (ω = 0.73), preoccupation (ω = 0.74), lack of compliance (ω = 0.74), and withdrawal (ω = 0.93).
Conclusion
The BENDEP-SRQ-PV is an adequate measure of hypnotic dependence in the Brazilian population of chronic users. Our results support using the scale for follow-up in clinical and research applications and in correlational studies.
... 13 Up to 44% of long-term benzodiazepine users have persistent moderate to severe withdrawal symptoms when they attempt to discontinue the drug. 3,19 This survey and other reports suggest that benzodiazepine withdrawal symptoms show considerable interindividual variability and do not follow a predictable trajectory. Protracted withdrawal symptoms are more common than previously appreciated. ...
Background
Over 92 million prescriptions for benzodiazepines are dispensed in the United States annually, yet little is known about the experiences of those taking and discontinuing them.
Objective
The aim of this study is to assess the experiences of those taking, tapering, or having discontinued benzodiazepines.
Methods
An online survey ( n = 1207) elicited information about benzodiazepine use, including long-term use, tapering, discontinuation, and withdrawal symptoms.
Results
Symptoms associated with benzodiazepine use, tapering, and discontinuation were numerous and ranged from symptoms such as anxiety, insomnia, and nervousness to digestive problems, irregular heart rhythms, uncontrollable anger, photosensitivity, balance problems, and others. When asked how benzodiazepine symptoms affected their lives, 82.9% reported work problems, 86.3% had problems with social interactions and friendships, and 88.8% had problems with fun, recreation, and hobbies. Suicidal thoughts or attempted suicide was reported by 54.4%, and 46.8% said benzodiazepines caused lost employment. Most of the respondents for whom benzodiazepines were prescribed (76.2%) stated they had not been informed that benzodiazepines were indicated for short-term use only and that discontinuation might be difficult. About a third (31.5%) reported food allergies and/or seasonal allergies that occurred only after benzodiazepine use.
Conclusion
The trajectory of those who taper or discontinue benzodiazepines is unpredictable, and many patients experience a range of protracted and severe symptoms, even years after benzodiazepines were completely discontinued. Greater awareness is needed for both prescribers and patients about the potential for a difficult withdrawal from benzodiazepines.
... In addition to the semi-structured interviews, participants completed a brief online questionnaire to gather demographic data, historic and current BZD use, and screens for mental and physical health. The latter enabled a summary of the clinical characteristics of the sample, and included the Patient Health Questionnaire-9 (PHQ-9; (36)) to assess depressive symptoms, Generalised Anxiety Disorder-7 (GAD-7; (37)) to assess symptoms of anxiety, and the Health Survey Short-Form-8 (SF-8; (38)) to assess physical health, and the Severity of Dependence Scale (SDS; (39)) to assess the level of BZD dependence. The interview guide was piloted before use, and initially invited participants to share their story about how they came to be prescribed a BZD, as well as exploring the advantages and disadvantages of taking their medication. ...
Background:
Given the prevalence of long-term benzodiazepine (BZDs) prescribing, increased monitoring through the implementation of prescription monitoring programs (PMPs) may be the necessary impetus to promote BZD deprescribing. Despite evidence promoting the importance of patient-centred care, GPs have not been sufficiently supported to implement these principles through current deprescribing practice.
Aim:
To investigate patients' perception of their prescriber's influence on ceasing BZD use, including their willingness to take on their advice, and to understand how a patients' stage of change influences the barriers and facilitators they perceive to discontinuing BZDs.
Design and setting:
An online survey and qualitative interviews with 22 long-term BZD users (≥6 months), aged 18-69 years, recruited from the general population in Victoria, Australia.
Method:
Two groups of BZD users participated, one in the process of reducing their BZD and one not reducing, and were categorised according to their stage of change. Data underwent thematic analysis to identify barriers and facilitators to reducing BZDs both at the patient-level and prescriber-level.
Results:
BZD patients' perceptions of the prescriber influence were characterised by prescribing behaviours, treatment approach, and attitude. Barriers and facilitators to reducing their BZD were mapped against their stage of change. Irrespective of their stage of change, participants reported they would be willing to try reducing their BZD if they trusted their prescriber.
Conclusion:
This study illustrates that with a few key strategies at each step of the deprescribing conversation, GPs are well-positioned to tackle the issue of long-term BZD use in a manner that is patient-centred.
Aims
In this study, we tested the validity of the Severity of Dependence Scale in detecting dependence behaviours in patients with chronic migraine and medication overuse (CM + MO) using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the Leeds Dependence Questionnaire as gold standard measures.
Methods
Four hundred and fifty-four patients with CM + MO filled in the Severity of Dependence Scale and the Leeds Dependence Questionnaire and underwent a psychological evaluation for the diagnosis of substance dependence according to the DSM-IV criteria.
Results
Sixty-nine percent of subjects (n = 313) presented substance dependence according to the DSM-IV criteria. These patients scored significantly higher than those without substance dependence in Severity of Dependence Scale total score ( Z = −3.29, p = 0.001), and in items 1 ( Z = −2.44, p = 0.015), 2 ( Z = −2.50, p = 0.012), 4 ( Z = −2.05, p = 0.04), and 5 ( Z = −3.39, p = 0.001). Severity of Dependence Scale total score ( β = 0.13, SE = 0.04, z = 3.49, p < 0.001) was a significant predictor for substance dependence. Receiver Operating Characteristic (ROC) curves showed that Severity of Dependence Scale discriminated patients with or without substance dependence.
Conclusion
Severity of Dependence Scale could represent an interesting screening tool for dependency-like behaviors in CM + MO patients.
Panic attacks may present with conspicuous respiratory symptoms, which may also occur between attacks. Patients with panic attacks and respiratory symptoms have increased susceptibility to respiratory panicogenic challenges than patients without respiratory symptoms. Highly stressful situations, which may trigger a severe anxiety state such as panic attacks are characterized by a prothrombotic phenotype that increases the risk of thromboembolic events. Although episodes of pulmonary embolism might be accompanied by panic attacks, pulmonary embolism is seldom suspected when anxiety is the most likely alternative diagnosis. Given that recurrent thromboembolic disease may complicate with pulmonary artery hypertension and death, the diagnosis of pulmonary thromboembolism is fundamental. The diagnosis of pulmonary thromboembolism requires a high index of suspicion, because showers of microemboli are often asymptomatic or they may present with dyspnea, cough and wheezing, mimicking asthma. Notably, many patients with pulmonary thromboembolism have a relatively clear chest X-rays while severely hypoxemic. Confirmation of diagnosis usually depends on ventilation/perfusion lung scan or invasive imaging studies, such as computed tomographic pulmonary angiography. This paper discusses the characteristics of panic attacks that invite the suspicion of pulmonary embolism. It also suggests some diagnostic algorithms that help rule out thromboembolic disorders in the setting of panic attacks.
Benzodiazepines continue to be prescribed widely in the management of patients with insomnia or anxiety disorders, despite the availability and acceptability of alternative pharmacological and psychological treatments. Many patients will experience adverse effects during treatment and considerable distress when the dosage is reduced and stopped. Management of benzodiazepine withdrawal includes measures to prevent the development of dependence, careful attention to underlying medical conditions, medication consolidation and gradual dosage reduction, accompanying psychological interventions, occasional prescription of concomitant medication, and relapse prevention with on‐going support to address psychosocial stressors. There is a need for easier patient access to services with refined expertise and further research to optimise strategies for preventing dependence and facilitating withdrawal.
Background: Assessment and Screening of Assistance Needs (ASAN-Drugs) has its objective to identify the severity of drug consumption through 28 items. This instrument allows for the matching of severity levels of the degree of care needed to allow the orientation of the person in the service that corresponds to his/her case and needs. The aim of this research is to assess the factorial validity and reliability of the Arabic version of the ASAN-D.
Methods: The study included a sample of 53 participants; all of them were males (100%). Participants' age ranged from 18 to 50 with a mean age (SD) of 31.5 (6.27).
Results: The results of the exploratory factor analysis demonstrated a one-factor solution which explained 61% of the total sample. Through confirmatory factor analysis, this model can be considered as satisfactory. Reliability was good in the total sample (α = .84).
Conclusions: According to these results, the factorial validity of the Arabic version of the ASAN-D appears as a helpful assessment instrument to detect the degree of assistance needed and to better orient the individual in the appropriate service in Saudi Arabia.
Abbreviations: SDS: Severity of Dependence Scale; ASAN-D: Assessment and Screening of Assistance Needs – Drugs; DUIS: Drug Use Impact Scale; EFA: exploratory factor analysis
This extensively revised new edition provides a practical guide to understanding, assessing and managing physical, psychological and social complications related to drug and alcohol use. It presents a clear review of the aetiology, epidemiology, prevention and treatment of the problematic use of and dependence on alcohol, illicit and prescribed drugs. In doing so it strikes a balance between theory, recent research and practical clinical guidance. New chapters focus on novel psychiatric substances, smoking cessation interventions, mutual aid groups and family interventions. Written by leading specialists in the field and closely following the MRCPsych curriculum, this book is an ideal resource for trainees preparing for their RCPsych membership examinations, but is also relevant to psychiatrists at all career levels. It will also appeal to other healthcare professionals, all of whom should be able to screen for alcohol and drug use disorders, deliver brief interventions, and signpost those with more severe disorders to specialist care.
Benzodiazepines are efficacious and well tolerated in clinical use. Besides the anxiolytic effects, they present sedative, muscle relaxant and anticonvulsive properties. Concerns regarding their use rely on drug dependence after prolonged used and difficult to manage withdrawal symptoms during drug discontinuation. Studies show that treatment duration up to 12 weeks is insufficient to reach maximal possible therapeutic effect and relapse during or shortly after drug discontinuation is frequent. Rebound and intolerable adverse events during drug discontinuation can be avoided in most cases if the dose is slowly down titrated in small decrements over a prolonged period of time. Most recent treatment guidelines recommend selective serotonin reuptake inhibitors (SSRI) as the first choice for the treatment of PD and the benzodiazepines have the reputation to cause dependence, especially if they are taken for long-term and in high doses. However these recommendations are mainly based on expert opinions mainly supported by a large number of clinical trials with SSRI since evidence coming from direct drug comparisons in PD is sparse. The SSRI have side effects and need a gradual tapering out too. There is no doubt that every substance must be prescribed with clinical concerns and indications. The benzodiazepines are efficacious in PD and the physician can manage the concern about dependence and withdrawal. It is very important to include this class of drugs in the armamentarium for treating PD.
The elderly have traditionally thought to have low rates of illicit drug use and higher rates of prescription drug misuse. This may change as a generation of lifetime drug users enter old age and strict guidelines limit the amount of sedative hypnotics prescribed. This chapter discusses the prevalence, correlates and trends of drug misuse in the elderly, focussing in particular on benzodiazepines and illicit drugs. The latest advances in detection, screening and treatment are discussed. The provision of appropriate and accessible treatment services for elderly drug misusers remains a major challenge to health care providers.
Background:
Early identification of problems is essential in minimising the unintended consequences of opioid therapy. This study aimed to develop a brief scale that identifies and quantifies recent aberrant behaviour among diverse patient populations receiving long-term opioid treatment.
Method:
40 scale items were generated via literature review and expert panel (N=19) and tested in surveys of: (i) N=41 key experts, and (ii) N=426 patients prescribed opioids >3 months (222 pain patients and 204 opioid substitution therapy (OST) patients). We employed item and scale psychometrics (exploratory factor analyses, confirmatory factor analyses and item-response theory statistics) to refine items to a brief scale.
Results:
Following removal of problematic items (poor retest-reliability or wording, semantic redundancy, differential item functioning, collinearity or rarity) iterative factor analytic procedures identified a 10-item unifactorial scale with good model fit in the total sample (N=426; CFI=0.981, TLI=0.975, RMSEA=0.057), and among pain (CFI=0.969, TLI=0.960, RMSEA=0.062) and OST subgroups (CFI=0.989, TFI=0.986, RMSEA=0.051). The 10 items provided good discrimination between groups, demonstrated acceptable test-retest reliability (ICC 0.80, 95% CI 0.60-0.89; Cronbach's alpha=0.89), were moderately correlated with related constructs, including opioid dependence (SDS), depression and stress (DASS subscales) and Social Relationships and Environment domains of the WHO-QoL, and had strong face validity among advising clinicians.
Conclusions:
The Opioid-Related Behaviours In Treatment (ORBIT) scale is brief, reliable and validated for use in diverse patient groups receiving opioids. The ORBIT has potential applications as a checklist to prompt clinical discussions and as a tool to quantify aberrant behaviour and assess change over time.
Cognitive behavioral therapy for insomnia (CBT-I) is an effective, non-pharmacological intervention, designated by the American College of Physicians as the first-line treatment of insomnia disorder. The current randomized controlled study uses a Hybrid-Type-1 design to compare the effectiveness and implementation potential of two approaches to delivering CBT-I in primary care. One approach offers therapy to all patients through an automated, digital CBT-I program (ONLINE-ONLY). The other is a triaged STEPPED-CARE approach that uses a simple Decision Checklist to start patients in either digital or therapist-led treatment; patients making insufficient progress with digital treatment at 2 months are switched to therapist-led treatment. We will randomize 240 individuals (age 50 or older) with insomnia disorder to ONLINE-ONLY or STEPPED-CARE arms. The primary outcomes are insomnia severity and hypnotic medication use, assessed at baseline and at months 2, 4, 6, 9, and 12 after randomization. We hypothesize that STEPPED-CARE will be superior to ONLINE-ONLY in reducing insomnia severity and hypnotic use. We also aim to validate the Decision Checklist and explore moderators of outcome. Additionally, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we will use mixed methods to obtain data on the potential for future dissemination and implementation of each approach. This triaged stepped-care approach has the potential to improve sleep, reduce use of hypnotic medications, promote safety, offer convenient access to treatment, and support dissemination of CBT-I to a large number of patients currently facing barriers to accessing treatment.
Clinical trial registration: NCT03532282
No study has investigated psychological dependence on antidepressants in patients with panic disorder, which was addressed in this study. This study was carried out in four psychiatric clinics in Tokyo, Japan. Individuals were eligible if they were outpatients aged 18 years or older and fulfilled the diagnostic criteria for panic disorder (ICD-10). Assessments included the Japanese Versions of the Severity of Dependence Scale (SDS), the Self-Report Version of Panic Disorder Severity Scale (PDSS-SR), and the Quick Inventory of Depressive Symptomatology-Self Report. Eighty-four individuals were included; of these, 30 patients (35.7%) showed psychological dependence on antidepressants (i.e. a total score of ≥5 in the SDS). A multiple regression analysis showed that PDSS scores and illness duration were correlated positively with SDS total scores. A binary regression model showed that absence of remission (i.e. a total score of ≥5 in the PDSS) and longer duration of illness increased the risk of dependence on antidepressants. Approximately one-third of the patients with panic disorder, receiving antidepressants, fulfilled the criteria for psychological dependence on these drugs. The results underscore the need for close monitoring, especially for those who present severe symptomatology or have a chronic course of the illness.
Objective
The authors assessed the prevalence of opioid and benzodiazepine prescription drug misuse in older adults, the risk factors associated with misuse, and age-appropriate interventions.
Methods
Following PRISMA guidelines, a literature search of PubMed, PsycINFO, and EMBASE for peer-reviewed journal articles in English through April 2014 with updates through November 2015 was conducted for reports on misuse of prescription benzodiazepines and opioids in older adults. Relevant publications were reviewed that included participants age ≥65 years. Reference lists were manually searched for key identified articles and geriatric journals through April 2016. Information on the study design, sample, intervention, comparators, outcome, time frame, and risk of bias were abstracted for each article.
Results
Of 4,932 reviewed reports, 15 were included in this systematic review. Thirteen studies assessed the prevalence of prescription drug misuse and included studies related to opioid shopping behavior, assessment of morbidity and mortality associated with opioid and/or benzodiazepine use, frequency and characteristics of opioid prescribing, frequency of substance use disorders and nonprescription use of pain relievers, and health conditions and experiences of long-term benzodiazepine users. One study identified risk factors for misuse, and one study described the effects of provider education and an electronic support tool as an intervention.
Conclusion
There is a dearth of high quality research on prescription drug misuse in older adults. Existing studies are heterogeneous, making it difficult to draw broad conclusions. The need for further research specific to prescription drug misuse among older adults is discussed.
Psychiatry Trainees’ Attitudes, Knowledge, and Training in Addiction
Psychiatry—A European Survey
Previous research has shown that individuals with substance use disorder (SUD) and posttraumatic stress disorder (PTSD) have emotional processing difficulties. However, no studies have specifically investigated the role of emotional processing in those with co-morbid SUD-PTSD. This study investigated whether there are more emotional processing abnormalities among patients with SUD-PTSD, than those with either a single diagnosis of PTSD or SUD. Emotional processing was assessed in three groups [1) SUD (without PTSD); 2) PTSD (without SUD); and 3) co-morbid SUD-PTSD] using the Emotional Processing Scale (EPS-25) and the International Affective Picture System (IAPS). Each of the three groups reported evidence of emotional processing dysfunction relative to the normal population. Within the SUD-PTSD group there was significant evidence that the additional impact of trauma increased emotional processing dysfunction but less evidence to suggest that substance use increased emotional processing dysfunction further. These findings call into question current United Kingdom guidelines for the treatment of co-morbid SUD-PTSD, which recommend that the drug or alcohol problem should be treated first.
Goede diagnostiek is belangrijk voor de terechtzitting en de keuze van behandelingen ter vermindering van de kans op recidive. Vanuit de complexiteit van de justitiële context en doelgroep is een kritische houding, ervaring in het werken met justitiabelen en een hoge mate van professionaliteit van BIG-geregistreerde forensisch (gz- of klinisch) psychologen en psychiaters onontbeerlijk bij diagnostiek. Het gebruik van collaterale informatie is noodzakelijk, evenals een voor de doelgroep ontwikkeld instrumentarium dat zich richt op 1) de kans op recidive, 2) statische en dynamische risicofactoren voor recidive (o.a. verslaving en andere psychopathologie) en 3) factoren die een behandeling kunnen belemmeren of bevorderen, met vooral aandacht voor persoonlijkheidstrekken, motivatie, groepsgeschiktheid, intelligentie en indicaties voor de betrouwbaarheid van de informatie. De gangbare risicotaxatie-instrumenten voor gewelddadige recidive (PCL-R, HCR-20, VRAG, HKT-30 en SAPROF) zijn betrouwbaar en valide, maar nog onvoldoende geschikt om uitsluitend hierop ingrijpende beslissingen te baseren.
Background
Patients admitted to addiction treatment programs report high rates of concurrent opioid and benzodiazepine (BZD) use. This combination places individuals at high risk for accidental overdose and other serious consequences. However, little is known about the beliefs opioid users have about the consequences of BZD use.
Methods
We surveyed consecutive persons initiating inpatient opioid detoxification (N = 476; 95.0% enrollment) and identified 245 who reported BZD use in the past 30 days and/or had a positive toxicology. We compared those who did and did not report BZD use on demographic and substance use variables, and specific beliefs about the potential effects of BZDs.
Results
Participants averaged 32.2 years of age, 71.2% were male, 86.6% used heroin, and 68.7% reported injection drug use in the past 30 days. Over half (51.5%) used a BZD in the month prior to admission; of these, 26.2% (n = 64) reported being prescribed a BZD. Alprazolam (Xanax) was the most commonly used BZD (54%). Benzodiazepine users (versus non-users) were significantly more likely to be female and non-Hispanic White, use concurrent substances, and report past year overdose. Overall, nearly all BZD users endorsed accurate beliefs that BZDs can increase the risk of overdose and can be addictive. However, BZD users, relative to non-users, were significantly less likely to endorse some known adverse consequences of BZDs, such as risk of worsening depression and poor medication-assisted opioid treatment retention.
Conclusions
Delineating the full array of risks from combining BZDs and opioids should be a high priority in detoxification settings, given the increased risks associated with BZD misuse in this population.
Az indiai kender (Cannabis sativa) fő hatóanyaga a THC, illet ve a szintetikus kannabinoidok az agy CB1 típusú endocannabinoid receptorain fejtik ki hatásukat. A marihuána és a szintetikus kannabinoidok tartós használata függőséghez vezethet, ennek ellenére a fiatalok körében fogyasztásuk egyre népszerűbb, 2018-ban a felnőtt népesség 7,4%-a próbálta ki a kannabiszt, és 1,9% a szintetikus kannabinoidokat. Főleg a szintetikus kannabinoid fogyasztás terjed, 2018 végére a cannabis utáni negyedik helyről második helyre került a felmérések szerint (EMCCDA, 2018). A szintetikus kannabinoid termékekhez sokszor amfetamint, benzodiazepineket, ópiátokat is kevernek, emiatt hatásuk kiszámíthatatlan. A kannabisz és a kannabinoidok veszélyeit sokan alábecsülik, pedig a genetikai adottságaik miatt skizofréniára hajlamos, illet ve a szociális vagy pszichikai problémáik elől szerhasználatba menekülő fiatalok különösen veszélyeztetettek, a körükben végzett prevenció kiemelkedő jelentőségű lenne.
Benzodiazepines are among the most commonly prescribed psychiatric medications and have the potential for misuse. People with psychiatric disorders may have a heightened liability to the reinforcing effects of benzodiazepines. Yet, the prevalence of benzodiazepine misuse in psychiatric care settings is not well characterized. The aim of the current study was to characterize the prevalence and correlates of benzodiazepine misuse in a sample of adults receiving psychiatric treatment (N = 589). The majority of participants reported a lifetime history of benzodiazepine prescription (68%) and 26% reported a lifetime history of misuse (defined as use without a prescription or at a dose or frequency higher than prescribed). Multivariable analyses indicated that history of a benzodiazepine prescription and drug use problems were significantly associated with lifetime benzodiazepine misuse. People with a history of benzodiazepine prescription had four times higher odds of misusing benzodiazepines and the primary source of misused benzodiazepines was from family or friends. Results suggest that benzodiazepine misuse is not exclusive to substance use disorder populations. The misuse of benzodiazepines should be assessed in psychiatric settings. Further research is needed to understand the impact of benzodiazepine misuse in this population and to develop tools to identify those at risk for misuse.
BACKGROUND
On 1st February 2018, Australia rescheduled codeine to be a prescription only medication. Many concerns were associated with this change including financial costs, accessibility and the possibility of poorer pain management and a decline in physical and mental health if codeine could not be accessed. There is limited knowledge about the long term benefits and outcomes of these changes in the research literature and, as Australia has followed many countries in implementing this restriction on codeine, further study of the outcomes of rescheduling decisions is critical. The Codeine Cohort study aims to examine the impact of codeine rescheduling on individuals who regularly use over-the-counter (OTC) codeine.
OBJECTIVE
To examine the impact of rescheduling codeine from an OTC medication to a prescription-only medicine on the primary measures of codeine use and dependence in a cohort of people who are frequent consumers of OTC codeine. Secondary measures will include pain and coping, health service use and other outcomes.
METHODS
The Codeine Cohort study aims to recruit 300 participants Australia who regularly (at least a few times per week for the past 6 months) use OTC codeine. Participants will be followed up at three time points over a 12 month period following the rescheduling.
RESULTS
Information on demographics, codeine use and dependence, physical and mental health, medication use and health service use will be collected and analysed using mixed models. The first three rounds of data collection for the Codeine Cohort study are complete and data collection for the final time point is underway and will to be completed by August 2019.
CONCLUSIONS
The Codeine Cohort study will provide insight into outcomes (positive and negative) associated with codeine rescheduling for individual patients, which informs further community education and intervention. This study will give a broader understanding of the effectiveness of regulatory restriction as addressing non-medical use and harms with codeine.
CLINICALTRIAL
Not Applicable
Medication-overuse headache is a worldwide challenge as it affects 1–2% of the general population. Some people are more prone to medication overuse, which can be ascertained by applying five simple questions about dependence. Detoxification of the overused medication is a cheap and effective treatment strategy. A short advice seems to be sufficient for people from the general population whom seek their general practitioner. Treatment is often more complicated in neurologist and hospital settings, most likely due to a combination of treatment failure in general practice and co-morbidity of other disorders including different types of headaches.
The CIDI is a fully standardised, structured interview for the assessment of psychiatric disorders according to DSM-III-R and proposed ICD-10 criteria. The development of this interview has been the collaborative effort of researchers from 18 sites around the world. In a field trial to test the cross-cultural acceptability and reliability of the questions, there was found to be high acceptance and excellent reliability for the substance use questions, problems with the lengthy alcohol section, and difficulties translating relevant substance use concepts into different languages. There is therefore room for further improvement in the substance-related questions. There proved to be differences between ICD-10 and DSM-III-R regarding substance abuse and dependence disorders.
The CIDI is a fully standardised diagnostic interview designed for assessing mental disorders based on the definitions and criteria of ICD-10 and DSM-III-R. Field trials with the CIDI have been conducted in 18 centres around the world, to test the feasibility and reliability of the CIDI in different cultures and settings, as well as to test the inter-rater agreement for the different types of questions used. Of 590 subjects interviewed across all sites and rated by an interviewer and observer, 575 were eligible for analysis. The CIDI was judged to be acceptable for most subjects and was appropriate for use in different kinds of settings. Many subjects fulfilled criteria for more than one diagnosis (lifetime and six-month). The most frequent lifetime disorders were generalised anxiety, major depression, tobacco use disorders, and agoraphobia. Percentage agreements for all diagnoses were above 90% and the kappa values were all highly significant. No significant numbers of diagnostic disconcordances were found with lifetime, six-month, and four-week time frames.
A representation and interpretation of the area under a receiver operating characteristic (ROC) curve obtained by the "rating" method, or by mathematical predictions based on patient characteristics, is presented. It is shown that in such a setting the area represents the probability that a randomly chosen diseased subject is (correctly) rated or ranked with greater suspicion than a randomly chosen non-diseased subject. Moreover, this probability of a correct ranking is the same quantity that is estimated by the already well-studied nonparametric Wilcoxon statistic. These two relationships are exploited to (a) provide rapid closed-form expressions for the approximate magnitude of the sampling variability, i.e., standard error that one uses to accompany the area under a smoothed ROC curve, (b) guide in determining the size of the sample required to provide a sufficiently reliable estimate of this area, and (c) determine how large sample sizes should be to ensure that one can statistically detect differences in the accuracy of diagnostic techniques.
A short self-report questionnaire was developed to assess dependence on benzodiazepines (BZDs), the Benzodiazepine Dependence Questionnaire (BDEPQ). The BDEPQ is the first scale to assess dependence on BZDs comprehensively, as all existing scales focus exclusively on withdrawal symptoms.
To evaluate its internal consistency and construct validity, 302 regular BZD users were recruited from media advertisements and assessed on a number of measures. The BDEPQ was compared with measures of depression, anxiety, sleep quality, BZD withdrawal symptoms and neuroticism to assess its construct validity. A 3-4 month follow-up was conducted to assess the ability of the BDEPQ to predict changes in BZD consumption and future BZD withdrawal.
The BDEPQ was found to have high internal consistency and to be relatively stable over the follow-up period. Three subscales were identified, each with good internal consistency and temporal stability. The BDEPQ was able to predict the severity of withdrawal symptoms.
The BDEPQ was found to be a reliable and valid self-report instrument for the assessment of BZD dependence in samples approximating the general population of people using BZDs.
A postal survey was conducted among long-term benzodiazepine users. Seventy-one questionnaires were analyzed. Most of the 58 subjects who had tried to stop or reduce their medication at some time experienced a return of their symptoms. New symptoms occurred in 42% of subjects. The incidence of a withdrawal syndrome was found to be between 26% and 5% depending on the criteria used.
The Severity of Dependence Scale (SDS) was devised to provide a short, easily administered scale which can be used to measure the degree of dependence experienced by users of different types of drugs. The SDS contains five items, all of which are explicitly concerned with psychological components of dependence. These items are specifically concerned with impaired control over drug taking and with preoccupation and anxieties about drug use. The SDS was given to five samples of drug users in London and Sydney. The samples comprised users of heroin and users of cocaine in London, and users of amphetamines and methadone maintenance patients in Sydney. The SDS satisfies a number of criteria which indicate its suitability as a measure of dependence. All SDS items load significantly with a single factor, and the total SDS score was extremely highly correlated with the single factor score. The SDS score is related to behavioural patterns of drug taking that are, in themselves, indicators of dependence, such as dose, frequency of use, duration of use, daily use and degree of contact with other drug users; it also shows criterion validity in that drug users who have sought treatment at specialist and non-specialist agencies for drug problems have higher SDS scores than non-treatment samples. The psychometric properties of the scale were good in all five samples, despite being applied to primary users of different classes of drug, wing different recruitment procedures in different cities in different countries.
41 outpatients who were long-term consumers of diazepam in therapeutic dosage were gradually withdrawn from the drug over 3 months by stepwise reduction. In a double-blind procedure half the patients began withdrawal immediately and half after 8 weeks. Of 36 patients who completed treatment, 16 (44.4%) experienced true withdrawal phenomena on reducing their drugs, but 8 other patients had pseudo-withdrawal reactions at a time when their drug treatment was unchanged. The pseudo-withdrawal reactions consisted of an increase in anxiety symptoms only, whereas true withdrawal symptoms also included perceptual changes and psychotic symptoms. Examination of pharmacological and clinical predictors of withdrawal phenomena and later relapse showed that personality factors were the most important, patients with passive-dependent traits having a significantly greater prevalence of withdrawal reactions.
This paper reviews reliability and validity studies of the WHO - Composite International Diagnostic Interview (CIDI). The CIDI is a comprehensive and fully standardized diagnostic interview designed for assessing mental disorders according to the definitions of the Diagnostic Criteria for Research of ICD-10 and DSM-III-R. The instrument contains 276 symptom questions many of which are coupled with probe questions to evaluate symptom severity, as well as questions for assessing help-seeking behavior, psychosocial impairments, and other episode-related questions. Although primarily intended for use in epidemiological studies of mental disorders, it is also being used extensively for clinical and other research purposes. The review documents the wide spread use of the instrument and discusses several test-retest and interrater reliability studies of the CIDI. Both types of studies have confirmed good to excellent Kappa coefficients for most diagnostic sections. In international multicenter studies as well as several smaller center studies the CIDI was judged to be acceptable for most subjects and was found to be appropriate for use in different kinds of settings and countries. There is however still a need for reliability studies in general population samples, the area the CIDI was primary intended for. Only a few selected aspects of validity have been examined so far, mostly in smaller selected clinical samples. The need for further procedural validity studies of the CIDI with clinical instruments such as the SCAN as well as cognitive validation studies is emphasized. The latter should focus on specific aspects, such as the use of standardized questions in the elderly, cognitive probes to improve recall of episodes and their timing, as well as the role of order effects in the presentation of diagnostic sections.
Synopsis
The procedural validity of the computerized version of the Composite International Diagnostic Interview (CIDI-Auto) was examined against the consensus diagnoses of two clinicians for six anxiety disorders (agoraphobia, panic disorder (±agoraphobia), social phobia, simple phobia, obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD) and major depressive episode (MDE)). Clinicians had available to them all data obtained over a 2- to 10-month period. Subjects were 98 patients accepted for treatment at an Anxiety Disorders Clinic, thus, all subjects had at least one of the diagnoses being examined. While the CIDI-Auto detected 88·2% of the clinician diagnoses, it identified twice as many diagnoses as did the clinicians. The sensitivity of the CIDI-Auto was above 0·85 except for GAD, which had a sensitivity of 0·29. The specificity of the CIDI-Auto was lower (range: 0·47–0·99). The agreement between the CIDI-Auto and the clinician diagnoses, as measured by intraclass kappas, ranged from poor ( k = 0·02; GAD) to excellent ( k = 0·81; OCD), with a fair level of agreement overall ( k = 0·40). Canonical correlation analysis suggested that the discrepancies between the CIDI-Auto and clinicians were not due to different diagnostic distinctions being made. It is suggested that the CIDI-Auto may have a lower threshold for diagnosing anxiety disorders than do experienced clinicians. It is concluded that, in a sample where all subjects have at least one anxiety disorder diagnosis, the CIDI-Auto has acceptable validity.
Despite the fact that there have been many reports on benzodiazepine (BZD) dependence, consensus about its definition has not been reached. Reliable prevalence data to estimate the dependence liability of BZDs are therefore lacking. This study is the first to assess the prevalence of BZD dependence in out-patient BZD users (115-general practice (GP) patients, 124 psychiatric out-patients and 33 self-help patients) on the basis of the DSM-III-R and ICD-10 substance dependence criteria. Past year and lifetime diagnoses of BZD dependence were made by means of the Schedules for Clinical Assessments in Neuropsychiatry (SCAN). High prevalence figures were found, ranging from 40% in the GP patients (DSM-III-R past year) to 97% in the self-help patients (ICD-10 lifetime), indicating that BZD users run a high risk of developing BZD dependence. The clinical management of BZD use could benefit from further development of diagnostic instruments such as a self-report questionnaire which reflects the severity of BZD dependence.
To assess the extent, characteristics and determinants of benzodiazepine prescription in outpatient Primary Health Care.
A clinical audit of a stratified random sample of Primary Health Care Centres in the seven islands and 1.6 million inhabitants region of 'Canarias' in Spain was carried out. From those centres, a random sample of 1045 clinical records was reviewed and information on diagnosis, prescription and prescribed dosages was collected in a structured questionnaire. A multivariate logistic regression analysis was performed in order to determine the 'risk factors' for the use of benzodiazepines.
Benzodiazepine prescription was recorded in 23.4% of all clinical records; 87.7% of these were for benzodiazepines classified as anxiolytics (N05B) and 12.3% for hypnotics (N05C2). Benzodiazepine prescription was more common for women, elderly, widowed, divorced, low educational background, housewives and retired people. Using multivariate logistic regression, the probability of benzodiazepine prescription was found to be closely related to age, gender and employment status, but not with educational level. Prescribed Daily Doses were lower than Defined Daily Doses (DDD) in 77.1% of all anxiolytic prescriptions, but were in agreement with DDD in 90% of hypnotic prescriptions. The duration of treatment recorded in the clinical records was 25+/-21 months, with a range of 1 and 144 months. General Practitioners were responsible for 67% of all benzodiazepine prescription. Anxiolytics were prescribed as a single daily dose in 57% of the cases, and only 'at supper' in 48.6%.
In the general population attending Primary Health Care Centres of the Canary Islands Health System the prescription of benzodiazepines is higher for women and the elderly, and the most common use is chronic, with a duration of over 2 years in most cases. Anxiolytics are prescribed in doses which are much lower than those used as DDD and were used only 'at night' in almost half of the cases. This could represent an overlapping of the indications with hypnotics, and explain part of the huge difference in the use of anxiolytics in Spain compared with other figures in Europe. This fact must also be taken into account when making inferences of benzodiazepine use from sales statistics, which are very imprecise measures of drug use.
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