Elsevier

Drug and Alcohol Dependence

Volume 160, 1 March 2016, Pages 190-196
Drug and Alcohol Dependence

Full length article
Comorbid depression, antisocial personality, and substance dependence: Relationship with delay discounting

https://doi.org/10.1016/j.drugalcdep.2016.01.009Get rights and content

Highlights

  • Many with substance use disorder also have comorbid psychopathology.

  • Discounting is exacerbated in comorbid psychopathology and substance use.

  • Excessive discounting may be related to increased treatment failure.

Abstract

Background

Within the field of addiction, as many as four-fifths of individuals in treatment for substance use disorder have co-existing lifetime psychopathology and as high as two-thirds have current psychopathology. Among substance-dependent individuals, excessive delay discounting is pervasive. Despite evidence of excessive discounting across substance use disorders, few studies have investigated the impact of co-occurring psychopathologies and SUD on delay discounting.

Methods

We compared delay discounting in currently abstaining substance users with (a) SUD (n = 166), (b) SUD and managed major depressive disorder (MDD; n = 44), (c) SUD and antisocial personality disorder (APD; n = 35), (d) SUD and managed MDD and APD (n = 22) and (e) no SUD or co-occurring psychopathology (n = 60).

Results

All groups with SUD discounted future delayed rewards significantly more than healthy controls (p < 0.001 in each case, d = 0.686, 0.835, 1.098 and 1.650, respective to groups a–d above). Individuals with both APD and SUD and individuals with MDD, APD, and SUD discounted future rewards significantly more than substance users without comorbid psychopathology (p = 0.029, d = 0.412 and p < 0.001, d = 0.964, respectively).

Conclusions

Overall, individuals with multiple psychopathologies in addition to substance use have exacerbated deficits in discounting of the future, above and beyond that observed in substance use alone. Increased discounting in combined substance and psychopathology profiles suggest a greater chance of treatment failure and therefore may necessitate individualized treatment using adjunctive interventions to achieve better treatment outcomes.

Introduction

Excessive delay discounting, or the disproportionate devaluation of delayed rewards, is pervasive across substance use disorders (SUD; Coffey et al., 2003, García-Rodríguez et al., 2013, Heil et al., 2006, MacKillop et al., 2011, MacKillop and Kahler, 2009, Petry, 2001a, Vuchinich and Simpson, 1998). In SUD, increased delay discounting is tied to worsened treatment outcomes (Dallery and Raiff, 2007, Krishnan-Sarin et al., 2007, Passetti et al., 2008, Sheffer et al., 2012, Sheffer et al., 2014, Washio et al., 2011, Yoon et al., 2007). Moreover, substance users are more likely to have mental health problems than the non-dependent population (Farrell et al., 2001). Given that (1) SUD are associated with excessive rates of discounting, (2) excessive discounting is associated with worsened treatment outcomes, and (3) substance users have increased rates of mental health problems, the impact of comorbid psychopathology on discounting in substance using populations may be important to understand treatment outcomes and may suggest methods to improve treatment efficacy.

The extant literature is conflicting with respect to the impact of comorbidities on delay discounting. One report on attention deficit hyperactive disorder in combination with cocaine dependence did not observe increases in discounting of delayed rewards above the non-combined profile (Crunelle et al., 2013). Another study found that individuals with problem gambling and substance use disorders discounted significantly more than problem gamblers without substance use disorders (Andrade and Petry, 2012, Petry, 2001b). Yet another report found that individuals that smoked cigarettes, used alcohol, and gambled discounted significantly more than nonsmokers with alcohol and gambling problems (Andrade et al., 2013). The heterogeneity of findings and paucity of systematic comparisons across comorbid group profiles highlights the importance of additional clarification within this area. Specifically, here we assess the impact of co-occurring depression and/or antisocial personality disorder in substance users.

Clinically depressed individuals exhibit increased delay discounting (Pulcu et al., 2013, Takahashi et al., 2011). Takahashi et al. (2011) reported increased delay discounting in combined psychopharmocologically medicated (e.g., managed) depressed and bipolar individuals compared to nonaffected controls. So too, Pulcu et al. (2013) reported increased discounting of large rewards in individuals with current MDD symptomology (approximately half of which were currently taking anti-depressants) compared to non-medicated remitted MDD and nonaffected controls. Together, the extant literature on delay discounting and depression indicates that individuals with current depression symptomology show atypical patterns of delay discounting compared to healthy controls such that they discount large rewards more steeply than individuals with past or never depression. However, the impact of combined substance use and depression has not been examined.

Conflicting results have been reported in studies of delay discounting among those with APD. In one study, delay discounting was not observed to differ between SUD with and without APD (Sargeant et al., 2012). However, an earlier study reported that the SUD group discounted delayed rewards more than healthy controls and the SUD with APD group discounted more than the SUD group (Petry, 2002). The heterogeneity in these studies suggests the value of obtaining additional data to clarify the prior findings. The contrary results regarding SUD and APD could indicate one of two competing hypotheses. Either, combined SUD and APD may result in an additive effect on discounting or combined SUD and APD may result in a ceiling effect such that discounting does not increase above that observed in substance users. Given the current study’s findings, we will evaluate these competing hypotheses to bring clarity to the extant literature.

The extant literature on delay discounting in combined SUD and psychopathology profiles is largely heterogeneous. Here, we present data that addresses and systematically replicates previous findings to clarify and provide a unique comparison of comorbid MDD, APD, and SUD. Given that excessive discounting has been demonstrated to be associated with poorer treatment outcomes, any additive effect of discounting may suggest that supplemental treatment to improve future valuation may improve treatment outcomes. Of course, a competing hypothesis is that SUD results in such a degree of excessive discounting that additional psychopathology cannot engender any greater discounting in which case the implications for treatment would be nil.

Section snippets

Methods

In the current analysis, all participants provided written consent that was approved by either the IRB at University of Arkansas or Virginia Tech. Participants were community members from either the greater Little Rock metropolitan area in Arkansas or the greater Roanoke Valley region of Virginia. They were recruited via community outreach including flyers, postings on social media outlets including Facebook and Craigslist, and word of mouth. To participate, all participants had to (1) be at

Results

The goal of this study was to look at the effects of delay discounting on currently abstaining substance users with managed MDD and/or APD. We found increased delay discounting in combined substance use and psychopathology profiles. The CON group discounted significantly less than all other profiles (i.e., SUD, MDD/SUD, APD/SUD, MDD/APD/SUD) indicating that the CON group was less impulsive and displayed more self-control than all substance using groups. Adding to prior work on discounting in

Discussion

The current systematic evaluation of combined psychopathology and substance use offers clarity to the heterogeneous findings from the extant literature. The current finding that substance use in combination with managed MDD or APD is not associated with significantly greater discounting suggests a ceiling effect wherein the combination of MDD, or APD does not engender significantly greater dysregulation of the executive and impulsive decision systems. However, the combined profile of MDD, APD,

Role of funding

Nothing declared.

Contributors

WKB conceived the study idea and worked on manuscript, CTF oversaw statistical analyses and worked on manuscript, and LM oversaw project progress and worked on manuscript.

Conflict of interest

No conflict declared.

Acknowledgement

This study was funded by NIH grant R01DA024080.

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