Comparative Evaluation of Psychiatric Disorders in Opium and Heroin Dependent Patients†This article has been published in the Journal of Rafsanjan University of Medical Sciences in Persian language.

BACKGROUND: Opium dependency is an important health problem in Iran. Several studies show that most opium dependent patients have concomitant psychiatric disorders. The aim of this study was evaluation of psychiatric disorders in opium dependency in comparison with heroin dependency.
METHODS: This is a descriptive study on 192 male opium dependent patients who were admitted in dual- diagnosis ward of Beheshti Hospital in Kerman for detoxification. After evaluation of their demographic data, they were assessed by means of SCL-90-R test.
FINDINGS: The mean age of subjects was 33.92±7.67 years. All scales of SCL-90-R were evaluated as borderline or sick. The scores of obsession-compulsion, anxiety, phobia, psychosis, PST, and GSI were significantly higher in heroin dependents compared to opium dependent patients (P < 0.05).
CONCLUSION: It is recommended that all patients with opium dependency should be evaluated for co-morbid psychiatric disorders. This may improve the outcome and management of their dependency.

Introduction

Opium dependency is one of the major health problems in Iran. This disorder has negative impacts on patients and their family as well as the society. In order to deal with opium dependency, sufficient knowledge about different aspects of this phenomenon is necessary. Opium has been used for therapeutic purposes since long ago. It was a very common treatment for melancholia and mania in old medicine. In the first half of nineteenth century, opium was used for depression.1 Today opium and its derivations are no longer an accepted treatment for any disorder, but are identified as causes of many social, medical and psychological problems. It is reported that opium dependent patients also suffer from other mental problems. It is assumed that the pattern of taking opium is changing in Iran and the use of heroin instead of opium is more popular. In spite of recent actions to encourage people to stop taking opium, the numbers of opium dependents are still very high. A factor which might help physicians recognize and treat the addicts with higher chance for relapse is the accompanying mental disorders. For example, depression that is an easily diagnosed mood change is a risk factor for relapse.2

We studied the accompanying mental disorders in a group of opiate addicts using SCL-90-R test. Then, we divided them into two groups of opium and heroin dependents to compare their mental disorders.

Methods

We performed a cross-sectional study on 192 opium and heroin dependent male patients diagnosed based on DSM-V. The patients were admitted to dual-diagnosis ward in Beheshti Hospital in Kerman for detoxification from May to August 2002. At the time of admitting when there was no sign of withdrawal, the time and properties of taking opium showed no significant difference. After assessing the demographic patterns, patients were evaluated using SLC-90-R test. This test is appropriate for people more than 15 years of age and is a standard valid and reliable test in Iran.3, 4 It is also used for epidemiological surveys.5

This test has 90 questions, evaluating 9 different scales of physical complaints, obsession and compulsion, depression, anxiety, paranoid thoughts, phobia, psychosis, PST and GSI. There are also 7 miscellaneous questions. Each part of the test has a scale of 5 scores: 0 = Neil, 1 = little, 2 = some, 3 = very, 4 = severe. A part from the above scales, there are 3 other indices to be assessed after the questionnaires are done: Global Severity Index (GSI), Positive Symptom Total (PST) which is calculated by a 90-Question test and shows the minimum assessed disorders and/or number of questions with scores rather than zero, and Positive Symptom Distress Index (PSDI), which is calculated by dividing the total number of 90-Questions to PST and is a kind of distress severity evaluation.

Distress severity was evaluated as healthy, borderline, sick and very sick in SCL-90-R scale for the whole population. Comparison between two groups were performed using X and ANOVA tests and SPSS-9. P < 0.05 considered as significant.

Results

We studied 192 patients, 96 opium and 96 heroin dependents. Mean age for the subjects was 33.92±7.67. Mean age for the opium dependent patients was 33.73±8.42 and for heroin dependents was 34.12±6.85 (P = 0.72). Mean dependency years for opium was 3.71±1.41 and for heroin was 4.08±1.33 (P = 0.054). There was no significant difference between the education levels of the two groups. Mean scores for the phobia, interpersonal hypersensitivity and paranoid thoughts scales for the total population showed borderline and for the rest 10 indices showed a state in SCL-90-R. GSI showed borderline state (Table 1).

Table 1

Average of SCL-90-R test scale and the existence of psychopathology based on test guidelines in study sample

Criterion	M±SD	Distress Severity
Physical complaints	16.93±7.47	Sick
Obsession and compulsion	14.67±5.51	Sick
Sensitivity in communication	13.91±5.29	Borderline
Depression	19.68±7.52	Sick
Anxiety	14.08±6.21	Sick
Quarrelsome	9.07±3.03	Sick
Phobia	8.70±4.48	Borderline
Paranoid thoughts	8.92±4.47	Borderline
Psychosis	14.28±5.46	Sick
Extra questions	10.53±3.89	Sick
PST	66.27±19.02	-
PSDI	1.87±0.36	-
GSI	1.45±0.48	Borderline

SCL-90-R scales were compared between two groups and the scores for obsessive and compulsive, anxiety, phobia , psychosis, PST and GSI were significantly higher in the heroin dependent group (Table 2).

Table 2

Average of SCL-90-R test scale in opium and heroin dependent patients

Criterion Group	Opium dependent M±SD	Heroin dependents M±SD	Statistical analysis
			P value	F value
Physical complaints	15.94±7.72	17.92±7.13	Not Significant
Obsession and compulsion	13.65±5.04	15.69±5.76	0.01	6.80
Sensitivity in communication	13.38±5.19	14.44±5.37	Not Significant
Depression	18.92±7.51	20.47±7.50	Not Significant
Anxiety	13.52±6.01	16.11±6.17	0.004	8.56
Quarrelsome	8.94±3.13	21.9±2.94	Not Significant
Phobia	7.94±4.24	9.46±4.60	0.20	5.67
Paranoid thoughts	8.96±4.50	9.15±4.44	Not Significant
Psychosis	13.46±4.74	15.10±6.01	0.04	4.40
Extra questions	10.17±3.84	10.90±3.92	Not Significant
PST	62.90±20.92	69.78±16.21	0.01	6.71
PSDI	1.83±0.36	1.91±0.36	Not Significant
GSI	1.39±0.47	1.52±0.49	0.05	3.75

Discussion

Accompanying diagnosis to opium abuse and dependency are an important issue in psychiatry.

This study revealed that the whole population in this study was in sick category in most SCL-90-R scales. Although SCL-90-R test does not determine the type of disorder, as a screening test it shows the susceptibility of the population. Many studies around the world show the co-morbid axis I and II psychiatric disorders associated with opium dependency. A study reported that 86% of opium dependent patients had other axis I and II diagnosis and the most common co-morbid disorder was personality disorders and then mood and anxiety disorders.6

Mood disorders, especially depression was the most common psychiatric disorder in patients who had a self referral.7 A major study conducted in Lebanon showed that 64.9% of patients admitted for opium dependency had another psychiatric disorders.8 Results of the present study correlates with those conducted in the West, showing that opium dependency and co-morbid disorders are global phenomena and the prevalence is equal in Eastern and Western countries.9

Studies in the West are mostly conducted on heroin dependent patients whereas the present study aimed to find whether opium dependent patients from the psychiatric diagnostic criteria are different from heroin dependents. GSI and scales for obsession and compulsion, anxiety, phobia and psychosis were significantly higher in heroin dependents compared to opium dependents. These scales show that the level of anxiety is higher in heroin dependency. In a study using ICD-10 diagnostic criteria, 76% of heroin dependent patients had also an other co-morbid psychiatric disorder.10 Hopefully, symptoms of psychiatric disorders decrease during the cessation.7

Two important SCL-90-R scales (depression and hostility) showed no significant difference. The prevalence of depression in opiate dependent patients is higher than general population and it is even assumed to be effective in continuous abuse.11 Hostility scale also showed no significant difference between the two groups. Another study reported higher scores for anxiety and anger scales in opium dependent patients compared to control group and it was for all opiates regardless of their type.12

Our study shows that opiate dependent patients are generally more susceptible to psychiatric disorders and heroin dependent patients comparing to opium dependent patients are at least more susceptible to anxiety disorders. Psychiatric examination of all opiate dependent patients in order to treat their possible co-morbid disorders may improve the outcome of their treatment.