Elsevier

Drug and Alcohol Dependence

Volume 68, Issue 2, 1 October 2002, Pages 195-207
Drug and Alcohol Dependence

Mental disorders in ecstasy users: a prospective-longitudinal investigation

https://doi.org/10.1016/S0376-8716(02)00190-4Get rights and content

Abstract

Objectives: To investigate the relationship between ecstasy use and mental disorders in a representative sample of adolescents and young adults. Method: Data for this investigation were drawn from the Early Developmental Stages of Psychopathology (EDSP) study, an epidemiological–longitudinal study in which 14–24 year-olds were examined prospectively over a period of about 4 years. Results are based on N=2462 participants who completed the whole study period and for whom drug use behavior could be determined. Results: (1) Ecstasy users, compared with non-users, were at significantly increased risk of DSM-IV substance related disorders, including alcohol use disorders (52.6 vs. 15.6%; OR=5.6, 95% CI=3.8–8.1). Further, ecstasy users also had a higher risk of alcohol use disorders, when compared with users of other illicit substances (52.6 vs. 40.3%; OR=1.7, 95% CI=1.1–2.4). (2) Ecstasy users had significantly higher rates for almost all DSM-IV mental disorders examined when compared with non-users (any non-substance use disorder: 68.7 vs. 44.5%; OR=3.1, 95% CI=2.1–4.4) and compared with users of other illicit drugs (any non substance use disorder: 68.7 vs. 55.5%; OR=1.8, 95% CI=1.2–2.6). (3) Ecstasy users also reported significantly higher rates of prescription medicine use, though they did not use more medical services than non-drug users. (4) Analyses of temporal patterns of ecstasy use and disorder onset revealed that the first use of ecstasy was secondary to the onset of DSM-IV mental disorders in the majority of cases. Still, subjects with mental disorders at baseline also showed a significantly increased risk for initiation of ecstasy use during the 4-year follow-up period. Conclusions: Care should be taken in cross sectional studies in interpreting mental disorder signs and symptoms merely as a consequence of ecstasy use, as ecstasy use might be associated with the use of multiple substances, and onset of mental disorder is more likely to precede rather than to follow use of ecstasy and related substances.

Introduction

The World Health Organization (WHO) in 1996 acknowledged that 3,4-methylendioxy-N-methyl-amphetamin (MDMA), known as ‘Ecstasy’, and similar substances are becoming an established part of youth culture in some countries and that use is not generally perceived as dangerous (WHO, 1996). Epidemiological studies reveal that ecstasy use is common in the general population. A community survey of 3021 adolescents and young adults in the Munich (Germany) metropolitan area revealed in 1995 that 4% of the male and 2.3% of the female respondents aged 14–24 had used ecstasy, in addition to 3.6% of men and 1.6% of women who had used ecstasy-related substances (chemically related compounds, including amphetamines) (Perkonigg et al., 1998a). This rate was at least a 2-fold increase, compared with findings from a 1990 survey (Schuster et al., 1998), suggesting a considerable elevation in incidence within the past decade.

Pharmacologically, ecstasy pills should contain MDMA. However, Galliot-Guilley et al. (1999) showed that the generic term ‘ecstasy’ actually covers a wide variety of molecules with variable formulations. Their findings suggest only 22% of ecstasy pills to contain any MDMA. Similar results have been reported by other groups. In fact, ecstasy pills often contain other stimulating substances including caffeine, amphetamine and amphetamine derivatives, e.g. designer drugs, such as 3,4-methylendioxy-N-ethyl-amphetamin (MDE), 3,4-methylendioxy-amphetamin (MDA) (Sherlock et al., 1999, Christophersen, 2000).

Originally, ‘ecstasy’ was considered a relatively benign substance (Chesher, 1990, Solowij et al., 1992). Recent reports, however, show that use of ecstasy and related compounds may be associated with problems similar to those experienced by users of cocaine, including dependence (Morgan, 1998, Jansen, 1999). In addition to its rewarding effects, ecstasy's psychological effects may include cognitive deficits, confusion, depression, sleep problems, anxiety, and paranoia, sometimes lasting weeks after discontinuation of ecstasy use (Krystal et al., 1992, Wodarz and Böning, 1993, Parrott et al., 1998). Physical effects of ecstasy use may include muscle tension, involuntary teeth-clenching, nausea, blurred vision, faintness, and increases in heart rate and blood pressure (Liester et al., 1992, Gouzoulis-Mayfrank and Hermle, 1994, Thomasius et al., 1997, Schütz and Soyka, 1998, Vollenweider et al., 1998).

It has been a commonly held belief that recreational ecstasy use was infrequent with intermittent oral administration of little health concern (Beck and Rosenbaum, 1994). Reports have not only questioned the benign ‘pharmacological’ nature of ecstasy, but also its context. In an Italian study, Schifano and colleagues (Schifano et al., 1998) examined 150 ecstasy users presenting to the Padova Addiction Treatment Unit between 1991 and 1996 and found ecstasy use to be highly associated and intertwined with an extensive use of other licit and illicit substances. Furthermore, extensive psychopathology was found in this sample, including depression (32%), psychotic disorders (28%), cognitive impairment (27%), bulimia (24%) and panic attacks (12%). The authors concluded that psychopathology was substance induced but their findings are not generalizable to the community due to self-selection into treatment. Topp et al. (1999) found extensive polydrug use to be the norm among 329 ecstasy users in an Australian sample. Specifically, an average of eight physical and four psychological symptoms were attributed to ecstasy use within the last 6 months and one-fifth had sought professional help for a problem associated with ecstasy use. More recently, Pederson and Skrondal (1999) found that, among a sample of 10 812 adolescents aged 14–17 years in Oslo, ecstasy use was initiated subsequent to already existing use of other illicit substances, indicating that it was introduced late in a hypothesized drug use sequence. Epidemiological studies in unselected samples on the association between ecstasy use with DSM-IV mental disorders are lacking.

In sum, these findings suggest that use of ecstasy or related substances may be embedded in polydrug use and that use of ecstasy may be associated with significant mental problems and a wide range of mental disorders. However, results to date are limited in their generalizability to the community in at least two ways. First, previous studies are based solely on clinical samples. Therefore, it is not known whether the observed associations between ecstasy use and mental disorders exist among those who use ecstasy and do not seek help. Second, previous studies are cross-sectional. Therefore, it cannot be determined whether mental disorders precede or follow the initiation of ecstasy use. The current study allows us to fill this gap by using a prospective-longitudinal design to examine the relationship between ecstasy use and mental disorders among a representative sample of more than 3000 adolescents and young adults in the community.

The aims of this paper are 3-fold: (1) to evaluate the co-occurrence of ecstasy and related illicit drug use and DSM-IV mental disorders in a representative community sample of adolescents and young adults, unbiased by treatment selection or self referral; (2) to investigate the association between ecstasy use and utilization of medical and psychological services, as well as prescription medication use; (3) to examine whether use of ecstasy and related compounds precedes or follows the onset of mental disorders.

Section snippets

Design

The Early Developmental Stages of Psychopathology study (EDSP) is a prospective-longitudinal design based on a representative community sample of adolescents and young adults living in the Munich area, aged 14–24 years at baseline. The EDSP consists of a baseline investigation (T0), two follow-up investigations (T1, T2) and an independent parent survey. Detailed descriptions of the design have been presented elsewhere (see Wittchen et al., 1998a, Lieb et al., 2000).

Sample

The EDSP sample was drawn

Estimated cumulative lifetime use of ecstasy and other illicit substances

A total of 211 respondents (8.9%; percentages are adjusted by weights for sampling design) reported having used either ecstasy (6.6%) or any ecstasy-related substance including amphetamine (2.3%) at least once in their lifetime. Males reported use of ecstasy more frequently than females (10.4 vs. 7.5%; OR=1.4; 95% CI=1.0–2.0).

Almost 40% (39.7%) of the sample used illicit substances other than ecstasy, amphetamine or related compounds at least once, with higher rates in males than females (44.8

Discussion

Based on a 4-year prospective longitudinal (–) community study of 3021 subjects aged 14–24 at baseline the present paper confirmed earlier findings (Perkonigg et al., 1999, Schuster et al., 1998, Sydow et al., 2002), that the use of ecstasy and related substances is widespread in the community. Thus, at time in point of the second follow-up investigation, we observed a cumulative lifetime incidence rate of ecstasy use of 8.9% (males, 10.4%; females, 7.5%) of the total sample. The use of a

Acknowledgements

This work is part of the Early Developmental Stages of Psychopathology (EDSP) Study and is funded by the German Ministry of Research and Technology, project no. 01 EB 9405/6 and 01 EB 9901/6. Principal investigators are Dr Hans-Ulrich Wittchen (PI) and Dr Roselind Lieb (Co-PI). Current or former staff members of the EDSP group are Dr Kirsten von Sydow, Dr Gabriele Lachner, Dr Axel Perkonigg, Dipl.-Psych. Peter Schuster, Dr Franz Gander, Dipl.-Stat. Michael Höfler and Dipl.-Psych. Holger Sonntag

References (48)

  • M. Galliot-Guilley et al.

    Ecstasy and its ‘counterparts’

    Presse Med.

    (1999)
  • E. Gouzoulis-Mayfrank et al.

    Die Gefahren von Ecstasy

    Nervenarzt

    (1994)
  • M. Höfler et al.

    Covariates of cannabis use progression in a representative population sample of adolescents: a prospective examination of vulnerability and risk factors

    Addiction

    (1999)
  • J.H. Krystal et al.

    Chronic 3,4-methylenedioxymethamphetamine (MDMA) use: effects on mood and neuropsychological function

    Am. J. Drug Alcohol Abuse

    (1992)
  • G. Lachner et al.

    Structure, content and reliability of the munich-composite international diagnostic interview (M-CIDI). Substance use sections

    Eur. Addict. Res.

    (1998)
  • Lieb, R., Isensee, B., von Sydow, K., Wittchen, H.-U. 2000. The early developmental stages of psychopathology study...
  • M.B. Liester et al.

    Phenomenology and sequelae of 3,4-methylenedioxymethamphetamine use

    J. Nerv. Ment. Dis.

    (1992)
  • D.U. McCann et al.

    Serotonin neurotoxicity after (+/−)3,4-methylenedioxymethamphetamine (MDMA; ‘Ecstasy’): a controlled study in humans

    Neuropsychopharmacology

    (1994)
  • U.D. McCann et al.

    3,4-methylenedioxymethamphetamine (‘Ecstasy’) induced serotonin neurotoxicity: clinical studies

    Neuropsychobiology

    (2000)
  • P. McCullagh et al.

    Generalized Linear Models

    (1989)
  • A.C. Parrott et al.

    Cognitive performance in recreational users of MDMA of ‘ecstacy’: evidence for memory deficits

    J. Psychopharmacol.

    (1998)
  • W. Pederson et al.

    Ecstasy and new pattern of drug use: a normal population study

    Addiction

    (1999)
  • A. Perkonigg et al.

    Prevalence of use, abuse and dependence of illicit drugs among adolescents and young adults in a community sample

    Eur. Addict. Res.

    (1998)
  • A. Perkonigg et al.

    Substance use, abuse and dependence in Germany: a review of selected epidemiological data

    Eur. Addict. Res.

    (1998)
  • Cited by (133)

    • Cognitive consequences of 3,4-methylenedioxymethamphetamine use

      2020, Cognition and Addiction: A Researcher's Guide from Mechanisms Towards Interventions
    • MDMA-assisted therapy: A new treatment model for social anxiety in autistic adults

      2016, Progress in Neuro-Psychopharmacology and Biological Psychiatry
    • Using population screening for recruitment of young adults engaged in illicit drug use: Methodological issues and sampling outcomes

      2014, Social Science Research
      Citation Excerpt :

      Much illicit drug use occurs at low prevalence. Consequently, general population studies concerning ATS (i.e. methamphetamine and ecstasy) and other illicit drug use are often compromised by a lack of statistical power, even when broadly related drugs are grouped together (Lieb et al., 2002). Due to the threat of legal sanctions and social stigma, there is also a lack of available sampling frames.

    View all citing articles on Scopus
    View full text