|Year : 2021 | Volume
| Issue : 1 | Page : 1-8
The association of anxiety and depressive disorders with substance use disorders: frequency and relationship with substance use severity
Maha A Hassan, Mohamed A Abdelhameed, Salwa M.R Taha, Mohamed H Abdelhafeez
Department of Psychiatry, Faculty of Medicine, Minia University, Minia, Egypt
|Date of Submission||10-Mar-2020|
|Date of Decision||12-Mar-2020|
|Date of Acceptance||17-Mar-2020|
|Date of Web Publication||2-Apr-2021|
MD in Psychiatry Maha A Hassan
Department of Neurology and Psychiatry, El-Minia, El-Minia University Hospital, Minia 61111
Source of Support: None, Conflict of Interest: None
Background Substance use disorders (SUDs) are a common and potentially serious form of mental illness. Common associated mental illnesses include depressive and anxiety disorders.
Objectives To examine the frequency of comorbidity and the degree of severity of depressive and anxiety disorders with SUDs in a sample of upper Egyptian patients.
Patients and methods A total of 103 patients with SUDs were recruited. There were 95 males and eight females, with an age of 27.5±6.2, and two-thirds (67%) of them came from urban areas. They were subjected to complete substance use history, urine analysis screen for substances of abuse, Hamilton rating scales for anxiety and depression, and the Addiction Severity Index (ASI).
Results Overall, 41 (39.8%) patients began using substances before the age of 18 years, and 79 (76.7%) patients used more than one substance. Moreover, 74 (71.9%) patients had moderate or severe anxiety, whereas 78 (75.7%) patients had moderate or severe depression. Anxiety scores were positively and significantly correlated with three of the seven domains of ASI in addition to the duration of substance use, whereas depression scores were positively and significantly correlated with six of the ASI domains. Patients using polysubstances scored significantly higher than those using a single substance on anxiety and depressive scores.
Conclusions Anxiety and depressive disorders are frequently diagnosed in patients with SUDs. Increased severity of both types of disorders is associated with increased parameters of substance use severity. Using more than one substance increases the likelihood of having more severe anxiety and depressive illness.
Keywords: age, anxiety, ASI, depression, drug use, No. of drugs, sex
|How to cite this article:|
Hassan MA, Abdelhameed MA, Taha SM, Abdelhafeez MH. The association of anxiety and depressive disorders with substance use disorders: frequency and relationship with substance use severity. Egypt J Psychiatr 2021;42:1-8
|How to cite this URL:|
Hassan MA, Abdelhameed MA, Taha SM, Abdelhafeez MH. The association of anxiety and depressive disorders with substance use disorders: frequency and relationship with substance use severity. Egypt J Psychiatr [serial online] 2021 [cited 2021 Oct 18];42:1-8. Available from: http://new.ejpsy.eg.net/text.asp?2021/42/1/1/312997
| Introduction|| |
Addiction is a chronic, recurrent disease, with characteristic absolute advancement of drug-seeking behavior. The craving induced by substances of addiction dominates other behavior; the adaptation of a person to chronic intake of substances involves development of changes that are adaptive, sensitization, or tolerance (Vetulani, 2001).
Substance abuse in Egypt is a serious problem (Viney, 2012). A ‘national survey’ in 2007 reported that six million (8.5%) Egyptians (the majority of whom were between 15 and 25 years of age) were using drugs (Nasreldin et al., 2012). It has high prevalence among the young, varies according to the specific region of the country, more reported by boys than girls, and usually involves cannabis (Abou Eleinen et al., 2008).
In Egypt, the most commonly used drugs in the 1980s were cannabis, opium, solid and liquid hypno-sedatives, heroin, and lastly cocaine, in descending order of frequency (Okasha, 2004).
The United Nations Office on Drugs and Crime (2012) issued a global report that estimated 6–8% of Egypt’s population aged from 15 to 64 years used cannabis. Furthermore, the prevalence of smoking, illegal drugs, and over-the-counter drugs is increasing, especially among youth (Hamdi et al., 2013). In addition, the use of the water pipe (or shisha, as it is known in Egypt) has been increasing in cities and among new groups such as women, young people, and those from high socioeconomic levels (Labib et al., 2007).
The combination of a substance use disorder (SUD) and other psychiatric disorders is common. Substance misuse can probably activate new psychiatric disorders and worsen currently present ones (Johnson, 1997). In addition, psychiatric morbidity occurs with psychoactive substance use among adolescents (Kandel et al., 1999).
Commonly reported conditions include depression, suicidal ideation, attention-deficit/hyperactivity disorder, conduct disorder, anxiety, schizophrenia, and other psychoses (Hunt et al., 2002). Such comorbidity has been associated with increased psychiatric admission, violence (Scotte et al., 1998), suicidal behavior (Appleby et al., 1999), and poor treatment outcome in both substance misuse and psychiatric populations (Carey et al., 1991).
The relationship between anxiety disorders and substance-related disorders is complex. The interaction is not unidirectional, but variable and multifaceted. Anxiety symptoms often emerge during the course of chronic intoxication and withdrawal, and anxiety disorders may be a risk factor for the development of SUDs. Anxiety disorders change the clinical picture and treatment outcome for SUDs. Furthermore, SUDs modify the presentation and treatment outcome for anxiety disorders (Brady, 2012).Comorbid major depressive disorder (MDD) among persons with a SUD is associated with negative outcomes, including worse quality of life (Saatcioglu et al., 2008), increased chance of disability (Olfson et al., 1997), and higher suicide risk (Glasner-Edwards et al., 2008). At the initiation of treatment for SUD, patients with comorbid depression have more severe impairments in multiple areas, including social, medical, and legal problems. Additionally, MDD is the most common comorbid Axis I diagnosis for individuals with SUD (Leventhal et al., 2006).
| Patients and methods|| |
Setting of the study
Minia Hospital of Mental Health and Addiction Treatment is the official psychiatric hospital in Minia governorate (>4 million people). It is located at El Minia El Gadida City, which is at north-east of the Nile. It provides services for psychiatric patients and patients of substance abuse. Its inpatient capacity is 50 beds (40 for male patients and 10 for female patients). It provides an outpatient clinic service on daily basis and a hot line clinic for substance abusers on twice weekly basis (individual and group) and regular follow-up by phone calls with psychologists.
Patients of the study and size of the sample
All clients attending outpatient addiction clinic of Minia Psychiatric Hospital for 6-month duration (between 1st of December 2014 and 31st of May 2015) were subjected to screen for effect of substance abuse on the lifestyle of patients and evaluation of severity of addiction and its effect on mood. The approval of the Ethical Scientific Commute was obtained before the start of the research. Ethical Committee of Minia Faculty of Medicine approved this study.
Patients aged 18–60 years, whether males or females, with a positive history of SUD were included in the study, provided that they gave oral and written consent to participate in the procedure of the study.
However, patients younger than 18 years or older than 60 years, those with chronic illness, those with acute intoxication or withdrawal symptoms or substance-induced psychosis, and those who refused involving in the study were excluded from the study.
The final population sample of the present study included 103 patients of both sexes (95 males and eight females) who had SUD. They were diagnosed according to the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems, Diagnostic Criteria for Research (ICD-10) (World Health Organization, 1995).
Tools of the study
Urine analysis screen for substances of abuse
This was done in the Minia Hospital of Mental Health and Addiction Treatment laboratory by an experienced technician using two types of urine kits: the first is specific only for tramadol (DiaSpot Rapid One-step Test Device), and the second (ACON Urinalysis Reagent Strip) test for six different substances, such as THC (cannabis), BAR (barbiturate), COC (cocaine), AMP (amphetamine), MOP (morphine), and BZO (benzodiazepines).
Addiction Severity Index (McLellan et al., 1980)
The Addiction Severity Index (ASI) is a semistructured interview designed to provide a multidimensional assessment of problems presented by patients with SUDs. Information is collected by the index on seven functional areas mostly affected by substance use: medical status, employment and support, drug use, alcohol use, legal status, family and social status, and finally, psychiatric status.
Each section includes questions about the duration, frequency, and severity of problems over the whole patient’s life and in the past 30 days. Questions include the patient’s subjective assessment of the problems as well as objective indicators of problem severity. At the end of the assessment of each functional area, patients are asked to rate how troubled or annoyed they have been by these problems over the past 30 days and the degree to which they feel they need treatment. Moreover, it rated any current treatment they may be receiving for this problem area. Such ratings are made on a 0–4 scale. For each functional area, the interviewer also makes severity ratings that reflect the magnitude of the interviewer’s conviction that patient needs additional treatment, on a scale from 0 to 9 (McLellan et al., 1980).
The ASI has been extensively studied regarding joint reliability, test–retest reliability, and internal consistency of composite scores, with generally excellent results (McLellan et al., 1985). Hodgings et al. (1992) demonstrated average joint reliability scores of 0.89.
Hamilton Depression Rating Scale (Hamilton, 1960)
The Hamilton depression rating scale is a widely used semistructured interview that is used for assessing the presence and severity of depressive symptoms (Hamilton, 1960).
The original version contained 21 items, assessing depressive symptoms, including depressed mood, guilt, psychomotor retardation, insomnia, weight loss, somatic symptoms, and suicide. The first 17 items have five possible descriptors, which increase in severity and are scored on either a 0–4 scale. The other four items were included in the original Hamilton depression rating scale to assess the depressive disorder subtype (Bagby et al., 2004).
Hamilton anxiety rating scale (Hamilton, 1959)
The Hamilton anxiety rating scale is a widely used 14-item clinician-administered rating tool used to estimate the severity of anxiety symptoms among individuals previously diagnosed with anxiety disorders (McDowell, 2006).
The 14 items represent 13 categories of anxiety-related symptoms, including anxious mood, fear, tension, insomnia, intellectual/cognitive symptoms, depressed mood, general somatic, cardiovascular, respiratory, gastrointestinal symptoms, and genitourinary, with one item for the rater’s assessment of behavioral symptoms. The Hamilton anxiety rating scale contains two subscales − psychiatric anxiety (distress of psychological nature) as well as somatic anxiety (physical symptoms of distress) (Hamilton, 1959).
Retrograde longitudinal course of substance use disorder
The history of addiction is taken from the each client and includes the following:
- Onset of addiction.
- Causes of substance abuse.
- Decision of abstinence.
- Types of different substance.
- Doses of substances that were reached by patients.
- Causes of shifting from substance to another.
- Personal experience with each substance.
- Times of relapse.
- Duration of abstinence.
Data analysis and statistical methods
The data collected were recorded on a separate file for each patient and were given a code. Data analysis was done by the Statistical Package of Social Sciences (SPSS Inc., Chicago, USA), version 15.0 for Windows.
The data were summarized using the mean and SD for quantitative data and percent for qualitative data. Descriptive statistics of the study participants were conducted. Fisher exact test was used for qualitative data between each two groups like polysubstance and one-substance groups, and male and female groups. Differences between studied groups were considered statistically at P value less than 0.05.
| Results|| |
[Table 1] shows that the total sample of the study included 103 patients, comprising 95 (92.2%) males and eight (7.8%) females. The mean age was 27.5±6.2 years. A total of 69 (67%) patients came from urban areas, 51 (49.5%) patients of the sample were married, whereas the rest were single or divorced.
[Table 2] shows that more than half of the sample (53.4%) started taking drugs at an age ranging from 18 to 30 years, whereas 41 (39.85%) patients started taking drugs at age less than or equal to 18 years. Moreover, 24 (23.3%) patients used to take one substance, whereas polysubstance group included 79 (76.7%) patients.
[Table 3] shows that moderate anxiety was present in 43.7% of the sample, followed by severe anxiety (28.2%), mild anxiety (24.3%), and lastly, no anxiety (3.9%). On the contrary, frequency of depression in the sample was as follows: severe and very severe depression (42.7%) followed by moderate depression (33%), mild depression (18.4%) and then no depression (5.8%).
|Table 3 Frequency and severity of anxiety and depressive disorders in the sample|
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[Table 4] shows the correlation was positive between scoring of Hamilton anxiety rating scale and all subscales of ASI. The correlation was statistically significant for ASI psychiatric symptoms subscale (P<0.001), social subscale (P=0.007), and drug subscale (P=0.012). It was also statistically significant concerning duration of substance use (P=0.026).
|Table 4 Correlations between anxiety scoring and severity and some characteristics of addiction in the study sample|
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In [Table 5], there was a positive correlation between scoring of Hamilton rating scale of depression and all subscales of ASI. However, it was not statistically significant for ASI alcohol subscale, age of onset, or duration of intake of substance.
|Table 5 Correlations between depression scoring and severity and some characteristics of addiction in the study sample|
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[Table 6] shows that the mean value of one-substance group was 13.3±8.1 regarding scoring of Hamilton rating scale of anxiety, whereas the mean value of polysubstance group was 19.5±7.7. The comparison was highly statistically significant (P=0.001). Regarding Hamilton rating scale of depression, the mean value of one-substance group was 15.2±5.9, whereas the mean value of polysubstance group was 17.9±5.8, and the comparison was statistically significant (P=0.047).
|Table 6 Comparison between unisubstance and polysubstance use patients regarding the severity of associated anxiety and depressive disorders|
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| Discussion|| |
The current study was conducted in Minia Hospital of Mental Health and Addiction Treatment, which it is the sole official psychiatric hospital in Minia Governorate and provides in-patient and out-patient treatment for addiction. Previous studies directed at substance abuse in Egypt were carried out in the Ain Shams Institute of Psychiatry in Cairo (Khalil et al., 2008), whereas Loffredo et al. (2015) carried out their study in the streets of two largest cities in Egypt, Cairo and Alexandria. Mikhail et al. (2001) carried out their study from the Social Defence Club in Assiut and from psychiatric and addiction unit of Assiut University Hospital. El-Sawy et al. (2010) collected their sample from patients attending outpatient clinic in Neuropsychiatry Department in Tanta University Hospital. This difference in the setting with the current study led to some differences in the study results.
The total number of the study sample was 103 patients. This was in comparison with Metwally (1990), who studied 50 substance abusers (attendants of addiction centers in Cairo and Giza). Our sample was relatively less than Kamel et al. (1995), who studied files of all inpatients and outpatients attending the substance abuse unit of the Institute of Psychiatry Ain Shams University, where the total number was 179 patients. Abd El-Azim (2001) studied substance abuse among 154 substance abusers. However, El-Sawy et al. (2010) studied 457 addicts.
In the current study, we used ASI to detect drug/alcohol problems. This tool was previously used by Khalil et al. (2008) and Hamdi et al. (2013) to detect drug and alcohol problems.
In addition, the current study used Hamilton rating scales for depression and anxiety to detect comorbidity. El-Shafhy (1997) and El-Askary (2002) also used Hamilton rating scale for anxiety to detect comorbid anxiety between addicts. Ibrahim (2005) used Hamilton rating scale for depression to detect comorbid depression, whereas Subramaniam et al. (2009) used Beck Depression Inventory to detect MDD between substance abuser.
We also used addiction intensity scale to detect the severity of addiction, whereas Mikhail et al. (2001) used drug abuse questionnaire, which is a 20-item questionnaire that measures the abuse of drugs.
The total sample included 103 patients, with the mean age of 27.5±6.2 years. Males represented the majority of our cases (n=95; 92.2%), whereas females represented only eight (7.8%) patients. This may be explained on cultural basis, where males in our culture have earlier work career and hence, source of money to buy substances of abuse, in addition to more freedom and tolerance of behavior offered to males. These results were close to those obtained by El-Awady et al. (2017) who found that the incidence of substance use was higher in males (n=92; 92%) than in female (n=8; 8%) patients, but the mean age was 18.24±1.12 years, because they were adolescents.
These findings were nearly similar to those mentioned in a study by Khalil et al. (2008), who reported a 98% prevalence of males in their sample of 268 patients, with the mean age of 29 years. In another study by Mohamed et al. (2013) on 120 patients with substance-related disorders, 91.7% of the sample was males and 8.3% were females, with the mean age of 28.52±6.73. Hatata (2004) performed a study on a sample of 76 patients, where 70 (92.1%) patients were males and six (7.9%) patients were females.
In our study, 51 (49.5%) patients were married, 47.6% were single, and the rest were divorced. These findings were close to the results of the study reported by Okasha and Raafat (1988), where among 100 substance abusers, 45 were single, 41 married, and five patients were divorced. However, these findings were inconsistent with the results reported in a study by Abd El-Azim (2001) who found that polygamy was significantly higher among substance abuser, 74% of abusers were never married, and 8.4% of the abusers were divorced.
More than half of the sample (53.4%) started taking drugs at age ranging from 18 to 30 years, whereas 41 (39.85%) patients started taking drugs at the age of 18 years, but only 6.8% started to take drugs at the age above 30 years. This result was in agreement with the results by Abd El-Azim (2001) who stated that the progression of age decreased markedly the liability to take substance. In addition, they found that 46.8% of patients abuse cannabis and alcohol around the age of 15–17 years. This showed that this is the age of trying and peer pressure.
The prevalence of anxiety in our sample was as follows: moderate anxiety (43.7%) followed by severe anxiety (28.2%), mild anxiety (24.3%), and the rest had no anxiety. These results are close to a number of epidemiologic studies conducted over the past three decades, consistently indicating that anxiety disorders and SUDs co-occur more commonly than would be expected by chance alone (Regier et al., 1990; Kessler et al., 1994; Kessler et al., 1997).
In addition, these results are similar to extensive analyses from an epidemiological survey which was focused on comorbidity, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The results of these studies show that anxiety disorders were significantly related to both alcohol and drug use disorders. The pattern of results also shows that anxiety disorders were more strongly related to substance dependence (odds ratio=3.0–6.0). Generalized anxiety disorder had the highest associations with SUDs (odds ratio=9.5) (Compton et al., 2007).
Moreover, the results are nearly similar to the study of Metwally (1990) who found that 60% of a sample of 50 substance abusers had anxiety symptoms and to another study by Abd El-Azim (2001) who found that anxiety disorders were the most common diagnoses among his sample. Primary pathways to comorbidity have been suggested for such comorbidity (Hasin et al., 2007). These pathways include the following: (a) a self-medication pathway wherein an anxiety disorder leads to a SUD, (b) a substance-induced anxiety disorder pathway, and (c) a third variable pathway (e.g. genetics or anxiety sensitivity).
On the contrary, the frequency of depression in the current study was as follows: many of the patients had severe and very severe depression (42.7%) followed by moderate depression (33%), mild depression (18.4%) and then no depression (5.8%). The mean±SD of Hamilton rating scale of depression for all patients was 17.3±5.9.
These results are nearly similar to those obtained from a multicenter study on 6355 alcohol-dependent and drug-dependent patients from 41 sites, which indicated that 44% of these individuals also had a history of major depression (Miller et al., 1996). A similar study of more than 4000 patients revealed strong associations of both alcohol and drug use disorders with depression (Mezzich et al., 1990).
The results are nearly similar to those obtained from another study by Fahmy (1989) using the Beck Depression Inventory self-administered to users and controls to determine the depth of depression in both groups and to allow comparison between the two groups. It was revealed that the mean score of users was 20.29±8.63, which classified them in the category of moderate depression. However, the mean score of controls was 8.26±7.2, which signified that most controls either had no depression or only mild depression. In addition, Metwally (1990) found that among 50 substance abusers, 8% had major depression and 72% had depressive symptoms. This explains the strong relationship between depression and SUD.
Our study shows positive correlations between scoring of Hamilton anxiety rating scale and all subscales of ASI. The correlation was highly statistically significant for ASI psychiatric symptoms subscale, family subscale, social subscale, and drug subscale. However, the correlation was not statistically significant for medical, employment, legal, and alcohol subscales. Moreover, there was a positive correlation between the score of Hamilton rating scale of anxiety and addiction intensity scoring, which was statistically significant.
This is compared with another study which was done on comorbid substance dependence and anxiety disorders. Such comorbidity was associated with more severe psychiatric symptoms and impairment in social and employment domains (Gros et al., 2013). The presence of generalized anxiety disorder is associated with a more severity of SUD in form of rapid progression and chronic course with low rates of remission (Brady, 2012).
There are also several possible explanations for the observation. First, the addition of the comorbid anxiety disorder may result in an increased need to self-medicate, resulting in increased use of alcohol and polysubstance dependence, which leads to more severe complications as measured by ASI. Alternatively, it is possible that individuals with polysubstance dependence involving alcohol and/or sedatives are more likely to develop comorbid mood and anxiety disorders (Gros et al., 2013).
Our study provides positive correlations between scoring of Hamilton rating scale of depression and all subscales of ASI. These correlations were statistically significant for ASI psychiatry subscale, family subscale, drugs subscale, legal subscale, medical subscale, and employment subscale. However, it was not statistically significant for alcohol subscale. In addition, there was a positive correlation between scoring of Hamilton rating scale of depression and addiction intensity scoring, which was highly statistically significant.
Another study on comorbid substance dependence and depression group found that comorbidity affected all the scales of the ASI but reached a statistical significance for only the medical, social, and psychiatric subscales (Erfan et al., 2010). In addition, SUD patients with comorbid MDD had more severe impairments in multiple areas, including medical, legal, and social problems (Leventhal et al., 2006).
On the contrary, a study by Mohsen et al. (2001) found that the comorbidity affected all the scales of the ASI but did not reach a statistical significance in any scale except for the psychological and family subscale, which reached a borderline significance. This is also comparable with the results by Abdel Rehem (2006), who mentioned that the comorbidity with depression had an effect on worsening the medical, the drug use, legal, social, and the psychiatric subscales when compared with the noncomorbid group of patients with SUD in that study. These differences reached a significant difference only in the medical subscale.
Several authors suggested that psychiatric comorbidity is a factor in the severity of substance dependence (Belfer, 1993; Osher and Kofoed, 1995), and there was a study that provided evidence that greater frequency of use over time was associated with long-term worsening of depressive symptoms. In addition, the increased severity depressive symptoms were associated with worse status of SUD. The depressive symptoms may even be a particularly strong trigger for relapse (Worley et al., 2012).
| Conclusions|| |
Anxiety and depressive disorders are frequently diagnosed in patients with SUDs. Increased severity of both types of disorders is associated with increased parameters of substance use severity. Using more than one substance increases the likelihood of having more severe anxiety and depressive illness.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abd El-Azim KA. (2001). Psychosocial correlates of substance abuse (a study in an Egyptian sample) [MD thesis, supervised by Prof. Farouk Lotaief, Prof. Naglaa El Mahalawy, Dr. Aida Seif El Dawla, Dr. Tarek Assad]. Cairo: Faculty of Medicine, Ain Shams University.
Abdel Rehem HF. (2006). Substance dependence in a sample of Egyptian adolescents [MD thesis supervised by Prof. Dr. Momtaz Mohamed Ahmed Abdel Wahab, Prof. Dr. Lamis Ali El Ray, Prof. Dr. Salwa Mohamed Fawzy Erfan]. Cairo: Faculty of Medicine, Cairo University.
Abou Eleinen R, Mostafa M, Ghanem AE, Elnaggar E, Elbayomy A (2008). Psychoactive drug use in toxicology unit patients in Mansoura emergency hospital, Egypt. J Forensic Med Clin Toxicol 16:1–12.
Appleby L, Shaw J, Amos T (1999). Suicide within 12 months of contact with mental health services. Br Med J 318:1235–1239.
Bagby RM, Ryder AG, Schuller DR, Marshall MB (2004). The Hamilton Depression Rating Scale: has the gold standard become a lead weight?. Am J Psychiatry 161:2163–2177.
Belfer ML (1993). Substance abuse with psychiatric illness in children and adolescence Definitions and terminology. Am J Orthopsychiatry (63):70–79.
Brady K (2012). Comorbid anxiety and substance use disorders. In: Verster J, Brady K, Galanter M, Conrod P, (eds). Drug abuse and addiction in medical illness: causes, consequences and treatment. New York: Springer; 267:274.
Carey MP, Carey KB, Meisler AW (1991). Psychiatric symptoms in mentally ill chemical abusers. J Nerv Ment Serv 179:136–138.
Compton WM, Thomas YF, Stinson FS, Grant BF (2007). Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 64:566–576.
El-Askary RM (2002). Ego function & comorbid anxiety disorders in substance use disorders [MCs thesis]. Cairo: Faculty of Medicine, Cairo University.
El-Awady SHA, Elsheshtawy EA, Elbahaey WA, Elboraie OA (2017). Impact of familial risk factors on the severity of addiction in a sample of Egyptian adolescents. Egypt J Psychiatry 38:70–78.
El-Sawy H, Abdel Hay M, Badawy A (2010). Gender differences in risks and pattern of drug abuse in Egypt. Egypt J Neurol Psychiatry Neurosurg 47:413–418.
El-Shafhy KM (1997). Mood changes in addicts [MCs thesis]. Cairo: Faculty of Medicine, Cairo University.
Erfan S, Hashim A, Shaheen M, Sabry N (2010). Effect of comorbid depression on substance use disorders. J Subst Abuse 31:162–169.
Fahmy M. (1989). Heroin abuse: a study of its psycho demographic and clinical aspects among Egyptian inpatients [MD thesis]. Cairo: Faculty of Medicine, Ain Shams University.
Glasner-Edwards S, Mooney LJ, Marinelli-Casey P, Hillhouse M, Rawson R (2008). Risk factors for suicide attempts in methamphetamine-dependent patients. Am J Addict 17:24–27.
Gros DF, Melissa E, Milanak MS, Brady K, Back SE (2013). Frequency and severity of comorbid mood and anxiety disorders in prescription opioid dependence. Am J Addict 22:261–265.
Hamilton M (1959). The assessment of anxiety states by rating. Br J Psychiatry 32:50–55.
Hamilton M (1960). A rating scale for depression. J Neurosurg Psychiatry 23:56–62.
Hamdi E, Sabry N, Khoweiled A, Edward A, Enab D (2013). The National Addiction Research Program: prevalence of alcohol and substance use among women in Cairo. Egypt J Psychiatry 34:155–163.
Hasin DS, Stinson FS, Ogburn E, Grant BF (2007). Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 64:830–842.
Hatata HA. (2004). Dual diagnosis in substance use disorders [MD thesis]. Cairo: Faculty of Medicine, Ain Shams University.
Hodgings DC, El-Guebaly N, Armstrong S, Dufour M (1992). Implications of depression on the outcome of alcohol dependence: 3 years prospective follow-up. Alcohol Clin Exp Res 23:151–157.
Hunt GE, Bergen J, Bashir M (2002). Medication compliance and comorbid substance abuse in schizophrenia. Schizophrenia Res 54:253–264.
Ibrahim MA. (2005). Effect of comorbid depression on substance use disorders in a sample of Egyptian patients [MCs thesis]. Cairo: Faculty of Medicine, Cairo University.
Johnson S (1997). Dual diagnosis of severe mental illness and substance misuse. Br J Psychiatry 171:205–208.
Kamel M, Ghanem M, El-Mahallawy N, Saad A, Asaad T, Mansour M, Omar AM (1995). Characteristics of patients attending the substance abuse unit in the institutes of psychiatry. Ain Shams Univ Curr Psychiatry 2:184–191.
Kandel DB, Johnson JG, Bird HR, Weismann MM, Goodman SH, Lahey BB, Schwab-Stone ME (1999). Psychiatric comorbidity among adolescents with substance use disorders: findings from the MECA Study. J Am Acad Child Adolesc Psychiatry 38:693–699.
Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 51:8–19.
Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC (1997). Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry 54:313–321.
Khalil A, Okasha T, Mansour Shawky M, Haroon A, Elhabiby M, Carise D (2008). Characterization of substance abuse patients presenting for treatment at a University Psychiatric Hospital in Cairo. Egypt Addict Disord Treat 8:199–209.
Labib N, Radwan G, Mikhail N, Mohamed MK, Setouhy ME, Loffredo C, Israel E (2007). Comparison of cigarette and water pipe smoking among female university students in Egypt. Nicotine Tobacco Res 9:591–596.
Leventhal AM, Mooney ME, DeLaune KA, Schmitz JM (2006). Using addiction severity profiles to differentiate cocaine-dependent patients with and without comorbid major depression. Am J Addict 15:362–369.
Loffredo CA, Boulos DN, Saleh DA, Jillson IA, Garas M, Loza N (2015). Substance use by egyptian youth: current patterns and potential avenues for prevention. Subst Use Misuse 50:609–618.
McDowell I (2006). Measuring health: a guide to rating scales and questionnaires. (3rd ed). New York: Oxford University Press.
McLellan AT, Lubrosky L, Woody GE, Brien CP (1980). An improved diagnostic evaluation instrument for substance abuse patients, The Addiction Severity Index. J Nerv Ment Dis 168:26–33.
McLellan AT, Lubrosky L, Cacciola J, Griffith J, Evans F (1985). New data from addiction severity index. Reliability and validity in three centers. J Nerv Ment Dis 173:412–23.
Metwally HM. (1990). Relation between parents’ role and substance abuse in a sample of Egyptian males and females [MCs thesis]. Cairo: Faculty of Medicine, Al Azhar University.
Mezzich JE, Ahn CW, Fabrega H, Pilkonis P (1990). Patterns of psychiatric comorbidity in a large population presenting for care. In: Maser JD, Cloninger CR, (eds). Comorbidity of mood and anxiety disorders. Washington, DC: American Psychiatric Press. 189–204.
Mikhail M, Eissa MA, Labeeb SHA, El-Hamid SM (2001). The psychosocial aspects of drug addicts in Assiut Governorate. Bull Environ Res 4:33–44.
Miller NS, Klamen D, Hoffmann NG, Flaherty JA (1996). Prevalence of depression and alcohol and other drug dependence in addictions treatment populations. J Psychoactive Drugs 28:111–124.
Mohamed NR, Hammad SA, El Hamrawy LG, Rajab AZ, El Bahy MS, Soltan MR (2013). Dual diagnosis and psychosocial correlates in substance abuse in Menoufia, Egypt. Menouf Med J 26:114–121.
Mohsen MYA, Abdel Gawad TS, Halim Z, Hanna AW (2001). Psychiatric co-morbidity and the severity of psychoactive substance dependence. Egypt J Psychiatry 24:283–297.
Nasreldin M, Khoweiled A, Loza N, Hamdi E, Khairy N, Sidrak A (2012). Impact of the first national campaign against the stigma of mental illness. Egypt J Psychiatry 33:35.
Okasha A (2004). Focus on psychiatry in Egypt. Br J Psychiatry 185:266–272.
Okasha A, Raafat M (1988). Is it worth treating cases of heroin abuse as inpatients?. Egypt J Psychiatry 11:119–126.
Olfson M, Fireman B, Weissman M, Leon AC, Sheehan DV, Kathol RG (1997). Mental disorders and disability among patients in a primary care group practice. Am J Psychiatry 154:1734–1740.
Osher FC, Kofoed LL (1995). Development of program of care for people with a dual diagnosis of mental illness and substance abuse. Quouted from Mohsen MYA, et al., 2001, Psychiatric co-morbidity and severity of psychoactive substance dependence. Egypt J Psychiatry 24:283–297.
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK (1990). Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. J Am Med Assoc 264:2511–2518.
Saatcioglu O, Yapici A, Cakmak D (2008). Quality of life, depression and anxiety in alcohol dependence. Drug Alcohol Rev 27:83–90.
Scotte H, Johnson S, Menezes P (1998). Substance misuse and risk of aggression and offending among the severely mentally ill. Br J Psychiatry 172:345–350.
Subramaniam G, Harrell P, Huntley E, Tracy M (2009). Beck Depression Inventory for depression screening in substance-abusing adolescents. J Subst Abuse Treat 37:25–31.
United Nations Office on Drugs and Crime. [UNODC] (2012). World drug report 2012. Vienna: United Nations Office on Drugs and Crime. 112 p.
Vetulani J (2001) Drug addiction. Part I. Psychoactive substances in the past and presence. Pol J Pharmacol 53:201–214.
World Health Organization (1995). Geneva: International statistical classification of diseases & related health problems, tenth edition (ICD10), Diagnostic Criteria for Research, Geneva: World Health Organization.
Worley MJ, Trim RS, Roesch SC, Mrnak-Mey J, Tate SR, Brown S (2012). Comorbid depression and substance use disorder: longitudinal associations between symptoms in a controlled trial. J Subst Abuse Treat 43:291–302.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]