JOSEPH WESTERMEYER, JOHN NEIDER AND MICHELLE WESTERMEYER
SUBSTANCE USE AND OTHER PSYCHIATRIC DISORDERS AMONG 100 AMERICAN INDIAN PATIENTS ABSTRACT. One hundred American Indian patients with a Psychoactive Substance Use Disorder (PSUD) were studied with special reference to associated psychiatric disorders. This clinical sample was divided into three groups: PSUD only, PSUD plus an Organic Mental Disorder (OMD), and PSUD plus any other psychiatric disorder. OMD diagnoses included primarily Delirium Tremens and Alcoholic Hallucinosis; cases of Alcohol Amnestic Disorder, Alcohol Dementia, and trauma-induced OMD were also encountered. Other psychiatric disorders included primarily Major Depression and Anxiety Disorder, with smaller numbers of Schizophrenia, Conduct, Sexual, and other Disorders. Demographic and clinical characteristics were compared among these three groups. Those with PSUD + OMD tended to be older, male, and have more D S M - I I I Axis 3 disorders (American Psychiatric Association 1980) as compared to other patients; those with PSUD + other diagnoses tended to be single and younger. Education and occupational status were not related to the three diagnostic groups. The data were also subjected to MANOVA analysis. Even when corrected for sex, types of substance being abused, Axis 3 health status, and other factors, the three diagnostic groups still bore a significant relationship to age. Those with PSUD + Other psychiatric diagnoses besides OMD tended to be youngest. Those with PSUD-only were intermediate by age, while those with PSUD + OMD tended to be the oldest.
INTRODUCTION Dual disorder is defined for purposes of this paper as psychoactive substance use disorder (PSUD) associated concurrently in the same patient with any other psychiatric disorder. In the absence of data to the contrary, it cannot be stated that American Indians would differ from other Americans in the distribution of dual disorders. However, there are reasons to expect that some American Indian groups m a y have a different distribution o f psychiatric disorders associated with P S U D as compared to the population at large. Some possible sources o f a differing distribution of associated disorders are as follows: a high rate o f congenital mental retardation due to Fetal Alcohol Syndrome and fetal alcohol effects, as a result o f high rate of alcoholism in some American Indian groups (May et al. 1983) and due to inhalant abuse in teenagers of childbearing age (Padilla e t al. 1979); a high rate o f acquired mental retardation prior to age 15 as a result of volatile inhalant abuse in some American Indian groups (Beauvais et al. 1985; Kaufman 1975; Schottstaedt 1977; - episodic heavy "binge" drinking patterns among some tribes; "binge" patterns m a y favor brain injury, as well as withdrawal seizures and Delirium -
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Culture, Medicine and Psychiatry 16: 519-529, 1993. © 1993 Kluwer Academic Publishers. Printed in the Netherlands.
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Tremens (Westermeyer 1972; Donovan et al. 1985); age-related pattern of dual disorder, with more alcohol-related psychopathologies among older American Indian persons and more polydrug related psychopathologies among younger American Indians (Kivlahan et al. 1985; Rozynko et al. 1978); lower education levels and higher unemployment which fosters malnutrition and unhygienic conditions in homeless or Skid Row drinking groups (Foulks and Katz 1973; Westermeyer 1974); migration from reservations to cities, where social networks and tribal resources are often sparse (Westermeyer 1976); less access to treatment due to a) rural isolation of persons on remote reservations (Rozynko and Ferguson 1978); b) less access to treatment for economic reasons (Liban and Smart 1982; May et al. 1983); and c) the need, at times, to leave the American Indian society to achieve sobriety (Westermeyer and Peake 1983), thereby delaying treatment; - a relatively low rate of recovery as compared to other Americans (Westermeyer and Peake 1983: Kivlahan et al. 1985), so that more substance related psychiatric disorders ensue; a high rate of excessive drinking among American Indian patients with psychiatric disorders (Pelz 1981), perhaps as a means of self treatment due to poor availability of psychiatric care or low access to psychiatric care despite its availability; a high number of potentially addicting sedative drugs prescribed in some Indian Health Service settings (Kaufman et al. 1972); increasing sociocultural stress on American Indian persons over the last few decades (DeBruyn et al. 1988, Jones-Saumty and Zeiner 1985, Kroll et al. 1986); a higher rate of cross-racial foster placement and adoption of American Indian children than in the population at large, with subsequent identity problems and associated psychiatric disorders (Westermeyer 1979). -
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Despite these theoretical reasons for dual disorder among American Indian people, the limited literature on the topic (most of it p r e - D S M - l l l ) has shown little evidence of dual disorder among American Indian patients. In a survey of 432 American Indian psychiatric patients in Alaska, Foulks and Katz (1973) made no note of dual disorder. Similarly, Rozynko and Ferguson (1978) did not describe any psychiatric disorders other than alcoholism among 58 American Indian patients admitted to a California State Mental Hospital. Pelz et al. (1981) in a study of psychiatric inpatients and outpatients in Canada, remarked on "alcohol excess" in 15 out of 41 American Indian psychiatric patients (i.e., 37% prevalence rate of PSUD). However, Pelz et al. made "a primary diagnosis of
SUBSTANCE USE AND OTHER PSYCHIATRIC DISORDERS
521
alcoholism" in only 4 of the 41 cases (i.e., 10%), and none of these 4 cases received another associated psychiatric diagnosis. Thus, these three studies convey the notion that dual disorder among American Indian patients is nonexistent, or at least very infrequent. In a fourth study, depression symptoms were noted to be high in a group of treated American Indian alcoholics who continued drinking as compared to an abstinent group of treated American Indian alcoholics (Westermeyer and Neider 1984). The study reported here was carried out to answer the following four questions with regard to dual disorder among American Indian patients presenting to an alcohol-drug service: (1) Does associated psychiatric disorder occur among American Indian persons with PSUD? (2) If dual disorder does occur among American Indian patients with PSUD, what are the types of associated diagnoses (a qualitative question)? (3) If dual diagnosis does occur, what is the distribution of these disorders among American Indian persons with PSUD (a quantitative question)? and (4) If dual diagnosis does occur, what are the demographic correlates of these disorders among American Indian patients with PSUD? The rationale for this study was as follows: further knowledge regarding dual disorder among American Indian persons might facilitate better methods of assessment, more effective treatment interventions and rehabilitation programs, and more cost effective means of prevention.
METHOD
Sample Subjects consisted of 100 sequential American Indian inpatients and outpatients in the American Indian Alcohol Drug Treatment Program in the Department of Psychiatry at the University of Minnesota Hospitals and Clinics in Minneapolis. Referrals sources were diverse, including previously treated American Indian patients, other clinical services in the hospital, other medical facilities, American Indian organizations, social agencies, various professional persons, and institutions (e.g., tribal agencies, schools, courts). Tribal affiliation of the American Indian patients was predominantly Chippewa (also known as Ojibway or as Anishinabe), with about 20% identifying themselves as members of other groups (mostly Sioux, with several Cree, Seneca, Kiowa, and Blackfoot). Over 90% of this sample had been born on reservations. Data Collection Demographic information obtained from each subject included gender, age, education, current marital and occupational status. A Diagnostic and Statistical Manual Third Edition Revised (DSM-III-R, American Psychiatric Association, 1987) diagnosis was made that included all diagnoses for which criteria were
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JOSEPH WESTERMEYER ET AL.
met. The original "working diagnoses," but rather the diagnoses made after a period o f observation and care (usually lasting several weeks). An assessment was made after a period of observation and care (usually lasting several weeks). An assessment was made regarding the current substances of abuse for which the individual met diagnostic criteria. A clinical associate (nurse, social worker, or counselor) obtained data regarding previous treatment for PSUD and for other psychiatric disorders, and recorded information on any family history of substance abuse. Interviews for purposes of this study were collected at a time when the patients were not manifesting either intoxication or withdrawal and were not incapacitated with acute trauma or illness (e.g., pancreatitis, gastritis). Collateral sources of information were obtained in most cases.
Method of Analysis Nonparametric data were analyzed with two methods, depending on the number of subjects per cell. If the expected cell size was 5 or above, a Chi Square test was applied. If cell size was 5 or below and the analysis involved four cells, the Tables of the Hypergeometric Probability Distribution were applied. Student t, One way Analysis of Variance, and Pearson Correlation Coefficient tests were used to analyze parametric data. Serial M A N O V A analyses were conducted to correct for factors which might co-vary with age, such as sex, type of substance abused, and Axis 3 diagnoses. Univariate serial analyses were used due to the relatively small number of subjects relative to the numbers of variables and categories. RESULTS
Demography A m o n g these 100 patients were 71 men and 29 women. Their ages ranged from 8 to 61, with a mean of 32.9 years (standard deviation 12.4). Fourteen subjects were between age 8 and 19 years, including 4 pre-teenaged subjects with volatile inhalant abuse. Age distribution by deciles was as follows: 0-9 years = 1 patient; 10-19 years = 13 patients; 20-29 years = 27 patients; 30-39 years = 29 patients; 40--49 years = 17 patients; 50-59 years = 12 patients, and 60-69 years = 1 patient. Marital status included 51 single, 28 divorced and separated, 16 married and 5 widowed patients. Current employment status showed 64 unemployed, 22 employed, 13 students, and 1 retired person. Education ranged from 2 to 18 years, with a mean of 10.3 years (standard deviation 2.4). Religious affiliation was Christian in 49 cases, "Indian religion" in 13 cases, and other categories (mostly "no religion") in 38 cases. Only one pair of demographic characteristics were associated with one another to a statistically significant degree. Those who were single were younger than those who had ever been married (t = 5.45, 96 df, P
SUBSTANCE USE AND OTHER PSYCHIATRIC DISORDERS AMONG 100 AMERICAN INDIAN PATIENTS ABSTRACT. One hundred American Indian patients with a Psychoactive Substance Use Disorder (PSUD) were studied with special reference to associated psychiatric disorders. This clinical sample was divided into three groups: PSUD only, PSUD plus an Organic Mental Disorder (OMD), and PSUD plus any other psychiatric disorder. OMD diagnoses included primarily Delirium Tremens and Alcoholic Hallucinosis; cases of Alcohol Amnestic Disorder, Alcohol Dementia, and trauma-induced OMD were also encountered. Other psychiatric disorders included primarily Major Depression and Anxiety Disorder, with smaller numbers of Schizophrenia, Conduct, Sexual, and other Disorders. Demographic and clinical characteristics were compared among these three groups. Those with PSUD + OMD tended to be older, male, and have more D S M - I I I Axis 3 disorders (American Psychiatric Association 1980) as compared to other patients; those with PSUD + other diagnoses tended to be single and younger. Education and occupational status were not related to the three diagnostic groups. The data were also subjected to MANOVA analysis. Even when corrected for sex, types of substance being abused, Axis 3 health status, and other factors, the three diagnostic groups still bore a significant relationship to age. Those with PSUD + Other psychiatric diagnoses besides OMD tended to be youngest. Those with PSUD-only were intermediate by age, while those with PSUD + OMD tended to be the oldest.
INTRODUCTION Dual disorder is defined for purposes of this paper as psychoactive substance use disorder (PSUD) associated concurrently in the same patient with any other psychiatric disorder. In the absence of data to the contrary, it cannot be stated that American Indians would differ from other Americans in the distribution of dual disorders. However, there are reasons to expect that some American Indian groups m a y have a different distribution o f psychiatric disorders associated with P S U D as compared to the population at large. Some possible sources o f a differing distribution of associated disorders are as follows: a high rate o f congenital mental retardation due to Fetal Alcohol Syndrome and fetal alcohol effects, as a result o f high rate of alcoholism in some American Indian groups (May et al. 1983) and due to inhalant abuse in teenagers of childbearing age (Padilla e t al. 1979); a high rate o f acquired mental retardation prior to age 15 as a result of volatile inhalant abuse in some American Indian groups (Beauvais et al. 1985; Kaufman 1975; Schottstaedt 1977; - episodic heavy "binge" drinking patterns among some tribes; "binge" patterns m a y favor brain injury, as well as withdrawal seizures and Delirium -
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Culture, Medicine and Psychiatry 16: 519-529, 1993. © 1993 Kluwer Academic Publishers. Printed in the Netherlands.
520
JOSEPH WESTERMEYER ET AL.
Tremens (Westermeyer 1972; Donovan et al. 1985); age-related pattern of dual disorder, with more alcohol-related psychopathologies among older American Indian persons and more polydrug related psychopathologies among younger American Indians (Kivlahan et al. 1985; Rozynko et al. 1978); lower education levels and higher unemployment which fosters malnutrition and unhygienic conditions in homeless or Skid Row drinking groups (Foulks and Katz 1973; Westermeyer 1974); migration from reservations to cities, where social networks and tribal resources are often sparse (Westermeyer 1976); less access to treatment due to a) rural isolation of persons on remote reservations (Rozynko and Ferguson 1978); b) less access to treatment for economic reasons (Liban and Smart 1982; May et al. 1983); and c) the need, at times, to leave the American Indian society to achieve sobriety (Westermeyer and Peake 1983), thereby delaying treatment; - a relatively low rate of recovery as compared to other Americans (Westermeyer and Peake 1983: Kivlahan et al. 1985), so that more substance related psychiatric disorders ensue; a high rate of excessive drinking among American Indian patients with psychiatric disorders (Pelz 1981), perhaps as a means of self treatment due to poor availability of psychiatric care or low access to psychiatric care despite its availability; a high number of potentially addicting sedative drugs prescribed in some Indian Health Service settings (Kaufman et al. 1972); increasing sociocultural stress on American Indian persons over the last few decades (DeBruyn et al. 1988, Jones-Saumty and Zeiner 1985, Kroll et al. 1986); a higher rate of cross-racial foster placement and adoption of American Indian children than in the population at large, with subsequent identity problems and associated psychiatric disorders (Westermeyer 1979). -
a
n
-
-
-
Despite these theoretical reasons for dual disorder among American Indian people, the limited literature on the topic (most of it p r e - D S M - l l l ) has shown little evidence of dual disorder among American Indian patients. In a survey of 432 American Indian psychiatric patients in Alaska, Foulks and Katz (1973) made no note of dual disorder. Similarly, Rozynko and Ferguson (1978) did not describe any psychiatric disorders other than alcoholism among 58 American Indian patients admitted to a California State Mental Hospital. Pelz et al. (1981) in a study of psychiatric inpatients and outpatients in Canada, remarked on "alcohol excess" in 15 out of 41 American Indian psychiatric patients (i.e., 37% prevalence rate of PSUD). However, Pelz et al. made "a primary diagnosis of
SUBSTANCE USE AND OTHER PSYCHIATRIC DISORDERS
521
alcoholism" in only 4 of the 41 cases (i.e., 10%), and none of these 4 cases received another associated psychiatric diagnosis. Thus, these three studies convey the notion that dual disorder among American Indian patients is nonexistent, or at least very infrequent. In a fourth study, depression symptoms were noted to be high in a group of treated American Indian alcoholics who continued drinking as compared to an abstinent group of treated American Indian alcoholics (Westermeyer and Neider 1984). The study reported here was carried out to answer the following four questions with regard to dual disorder among American Indian patients presenting to an alcohol-drug service: (1) Does associated psychiatric disorder occur among American Indian persons with PSUD? (2) If dual disorder does occur among American Indian patients with PSUD, what are the types of associated diagnoses (a qualitative question)? (3) If dual diagnosis does occur, what is the distribution of these disorders among American Indian persons with PSUD (a quantitative question)? and (4) If dual diagnosis does occur, what are the demographic correlates of these disorders among American Indian patients with PSUD? The rationale for this study was as follows: further knowledge regarding dual disorder among American Indian persons might facilitate better methods of assessment, more effective treatment interventions and rehabilitation programs, and more cost effective means of prevention.
METHOD
Sample Subjects consisted of 100 sequential American Indian inpatients and outpatients in the American Indian Alcohol Drug Treatment Program in the Department of Psychiatry at the University of Minnesota Hospitals and Clinics in Minneapolis. Referrals sources were diverse, including previously treated American Indian patients, other clinical services in the hospital, other medical facilities, American Indian organizations, social agencies, various professional persons, and institutions (e.g., tribal agencies, schools, courts). Tribal affiliation of the American Indian patients was predominantly Chippewa (also known as Ojibway or as Anishinabe), with about 20% identifying themselves as members of other groups (mostly Sioux, with several Cree, Seneca, Kiowa, and Blackfoot). Over 90% of this sample had been born on reservations. Data Collection Demographic information obtained from each subject included gender, age, education, current marital and occupational status. A Diagnostic and Statistical Manual Third Edition Revised (DSM-III-R, American Psychiatric Association, 1987) diagnosis was made that included all diagnoses for which criteria were
522
JOSEPH WESTERMEYER ET AL.
met. The original "working diagnoses," but rather the diagnoses made after a period o f observation and care (usually lasting several weeks). An assessment was made after a period of observation and care (usually lasting several weeks). An assessment was made regarding the current substances of abuse for which the individual met diagnostic criteria. A clinical associate (nurse, social worker, or counselor) obtained data regarding previous treatment for PSUD and for other psychiatric disorders, and recorded information on any family history of substance abuse. Interviews for purposes of this study were collected at a time when the patients were not manifesting either intoxication or withdrawal and were not incapacitated with acute trauma or illness (e.g., pancreatitis, gastritis). Collateral sources of information were obtained in most cases.
Method of Analysis Nonparametric data were analyzed with two methods, depending on the number of subjects per cell. If the expected cell size was 5 or above, a Chi Square test was applied. If cell size was 5 or below and the analysis involved four cells, the Tables of the Hypergeometric Probability Distribution were applied. Student t, One way Analysis of Variance, and Pearson Correlation Coefficient tests were used to analyze parametric data. Serial M A N O V A analyses were conducted to correct for factors which might co-vary with age, such as sex, type of substance abused, and Axis 3 diagnoses. Univariate serial analyses were used due to the relatively small number of subjects relative to the numbers of variables and categories. RESULTS
Demography A m o n g these 100 patients were 71 men and 29 women. Their ages ranged from 8 to 61, with a mean of 32.9 years (standard deviation 12.4). Fourteen subjects were between age 8 and 19 years, including 4 pre-teenaged subjects with volatile inhalant abuse. Age distribution by deciles was as follows: 0-9 years = 1 patient; 10-19 years = 13 patients; 20-29 years = 27 patients; 30-39 years = 29 patients; 40--49 years = 17 patients; 50-59 years = 12 patients, and 60-69 years = 1 patient. Marital status included 51 single, 28 divorced and separated, 16 married and 5 widowed patients. Current employment status showed 64 unemployed, 22 employed, 13 students, and 1 retired person. Education ranged from 2 to 18 years, with a mean of 10.3 years (standard deviation 2.4). Religious affiliation was Christian in 49 cases, "Indian religion" in 13 cases, and other categories (mostly "no religion") in 38 cases. Only one pair of demographic characteristics were associated with one another to a statistically significant degree. Those who were single were younger than those who had ever been married (t = 5.45, 96 df, P
