Mental disorders in ecstasy users: a prospective-longitudinal investigation
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
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