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Psychosomatic Medicine 65:86-91 (2003)
© 2003 American Psychosomatic Society

ORIGINAL ARTICLES

Association Between Low Plasma Levels of Cholesterol and Relapse in Cocaine Addicts

Laure Buydens-Branchey, MD and Marc Branchey, MD

From the VA New York Harbor Healthcare System, Brooklyn Campus, and State University of New York–Health Science Center at Brooklyn, Brooklyn, New York.

Address reprint requests to: Laure Buydens-Branchey, MD, Brooklyn Campus (11S/BK), VA New York Harbor Healthcare System, 800 Poly Place, Brooklyn, NY 11209. Email: lbuydens{at}worldnet.att.net


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: In light of recent studies suggesting the existence of associations between low concentrations of cholesterol and various psychiatric disorders, we decided to explore relationships between cholesterol levels and relapse rates in a group of cocaine addicts who had undergone inpatient detoxification.

METHODS: The total cholesterol levels of 38 non–opiate-dependent and non–alcohol-dependent cocaine addicts were determined while they were hospitalized. Drug use was subsequently assessed 3, 6, and 12 months after patients were discharged from the hospital.

RESULTS: Comparisons of the cholesterol levels (obtained during hospitalization) of relapsers and nonrelapsers by analyses of covariance with age and weight as covariates revealed significantly lower cholesterol values in patients who relapsed at 3 months (p = .046), 6 months (p = .030), and 12 months (p = .019) after discharge.

CONCLUSIONS: This study showed an association between a low total cholesterol level and relapse rates in detoxified cocaine addicts. Reasons for the predictive value of low cholesterol levels for relapse for up to 1 year after cholesterol measurements were made are unclear. These data are preliminary and in need of replication.

Key Words: cholesterol • cocaine • addiction • relapse.

Abbreviations: ALT = alanine aminotransferase; ANCOVA = analysis of covariance; ASI = Addiction Severity Index; ASP = antisocial personality disorder; AST = aspartate aminotransferase; FA = fatty acid; HIV = human immunodeficiency virus; PUFA = polyunsaturated fatty acid; SCID = Structured Clinical Interview for DSM-III; 5-HT = serotonin (5-hydroxy-tryptamine).


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
In a review of six randomized, controlled prevention trials published in 1990, Muldoon et al. (1) found that the lowering of raised total cholesterol in middle-aged subjects by diet, drugs, or both was associated with a significant decrease in the number of deaths from coronary heart disease but not in total deaths. This discrepancy was attributed to a significant increase in the number of deaths due to suicides, homicides, and accidents. Subsequently, a number of large epidemiological studies showed that a low cholesterol (frequently defined as a plasma concentration below 160 mg/dl) was inversely associated with depression (2–6). A similar observation was made in studies involving smaller numbers of subjects (7, 8). Relationships between a low cholesterol and suicide were also explored. Several large prospective cohort studies conducted in general populations reported associations between a low cholesterol and subsequent risk of death from suicide and trauma (4, 9, 10). More recently, a primary prevention trial in men found that a low cholesterol was associated with an increase in death from suicide (11). An association between a low cholesterol and high suicidality (12) and attempted suicide (13–19) was also observed in groups of psychiatric patients. However, several studies did not show an inverse relationship between cholesterol and depression (20–23) or between cholesterol and suicide (24–26).

Studies exploring associations between cholesterol and violent/aggressive tendencies reported lower cholesterol levels in homicidal offenders with a habitually violent tendency under the influence of alcohol compared with offenders without this tendency (27), in criminals with antisocial personality disorder (ASP) compared with criminals with other unspecified personality disorders (28), in US Army veterans with ASP (29), in hyperactive boys with aggression disorders (30), in patients admitted to a forensic hospital for crimes of violence (31), and in patients in a long-term psychiatric hospital (32). On the other hand, no association between low cholesterol and aggression was found in psychiatrically hospitalized children (33) and in another sample of adults with ASP (34).

Literature on cholesterol in substance abusers is sparse, but the information available seems to indicate that cholesterol levels are lower in heroin and cocaine abusers who do not consume excessive amounts of alcohol than in general population samples. More than 20 years ago, cholesterol levels were measured by Ho et al. (35) in a group of opiate addicts living in Hong Kong where polydrug use and alcohol use were uncommon. The opiate addicts were found to have significantly lower cholesterol levels than control subjects. Subsequently, heroin addicts were found to have low total cholesterol levels by Gettler (36) and low total and high-density lipoprotein cholesterol levels by Maccari et al. (37). Gettler (36) also found low cholesterol levels in a group of cocaine abusers.

We wondered whether we could replicate the observation of Gettler of diminished cholesterol levels in cocaine abusers. Cholesterol determinations were obtained in a group of 38 non–opiate-dependent and non–alcohol-dependent cocaine abusers admitted to an inpatient rehabilitation unit. In light of the apparent increased vulnerability to the development of behavioral problems and psychiatric disorders of individuals with low cholesterol levels, we wondered whether a low cholesterol would be associated with an increase in relapse rates in these patients after their detoxification.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Patients
Patients selected for participation in this study were 38 men whose age (mean ± SD) was 36.8 ± 7.1 years. They were studied while hospitalized on a locked inpatient drug rehabilitation unit. They did not receive any medication, including cholesterol-lowering drugs, during their stay in the hospital. Patients were excluded from the study if they had a major physical illness or had liver function test values outside the normal range. Cutoff points were 9 to 72 IU/liter for ALT, 14 to 50 IU/liter for AST, and 3.3 to 4.7 g/dl for albumin. All patients were screened for hepatitis B and C and were excluded if found positive for these conditions. Only patients whose HIV status was known and who were HIV-negative were included. Patients with a history of intravenous use of any substance and patients who had used opiates in any form during the year preceding admission were also excluded from the study. They were screened with the Structured Clinical Interview for DSM-III (SCID) (38) and were enrolled in the study if they met DSM-III-R criteria for cocaine dependence but did not meet criteria for any other axis I disorder (including dependence on any substance besides cocaine). The presence of one or more axis II disorders was not an exclusionary criterion. Patients who met admission criteria were asked to sign informed consent and were administered the Addiction Severity Index (ASI) (39). Information was also obtained about the frequency of use of drugs or alcohol and maximum daily amounts and average amounts of substances consumed. Cholesterol measurements were made 2 weeks after admission to the hospital.

Follow-Up Assessments
Patients were discharged after a stay of 3 weeks on the inpatient unit. Follow-up interviews were scheduled 3 months, 6 months, and 1 year after discharge. The interviews were structured and aimed at eliciting information about resumption of use of substances. A follow-up ASI was administered, and information was obtained about frequency and amounts or substances used and inpatient admissions for drug and alcohol use. Relapse was defined as follows: 1) use of cocaine for at least 5% of the time elapsed between two interviews, 2) inpatient admission for cocaine abuse during the same period, 3) average daily intake of more than 1 g/kg of ethanol during the time elapsed between two interviews, and 4) inpatient admission for alcohol abuse during the same period.

None of the patients used heroin during the follow-up period. Once a patient was considered to have relapsed during any of the time intervals surveyed, he was considered to have relapsed for the duration of the follow-up period.

Statistical Analysis
Calculations were made with data collected from the patients available for follow-up for the entire 1-year period. Cholesterol levels were those obtained while patients were hospitalized. Comparisons of these levels in relapsers and nonrelapsers were performed 3 months, 6 months, and 1 year after discharge with analyses of covariance (ANCOVAs), using age and weight as covariates.

Patients were also divided into two groups as a function of whether their cholesterol level was above or below 160 mg/dl. The rates of relapse of the two groups during the follow-up period were compared with a Kaplan-Meier survival analysis (40).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Six patients (16%) were lost to follow-up during the 1-year period. Of these six patients, two did not show up for any follow-up interview, two were interviewed 3 months after discharge and had not relapsed, and two were interviewed at the 3- and 6-month time points and had not relapsed. These patients did not differ significantly from the relapsers and nonrelapsers in any of the sociodemographic or clinical characteristics shown in Table 1.


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  		TABLE 1. Sociodemographic and Clinical Characteristics of Nonrelapsers and Relapsersa
 
Data presented in Tables 1 and 2 and in Figure 1 were collected from the 32 individuals who were interviewed 3 months, 6 months, and 1 year after discharge from the ward. Sociodemographic, clinical, and laboratory data of relapsers and nonrelapsers obtained on their admission to the inpatient unit are shown in Table 1. There were no significant differences between the groups in age, race, weight, marital status, educational level, cocaine and alcohol use, and in the percentages of individuals who met criteria for personality disorders, although relapsers tended to be more frequently divorced or separated and tended to have used cocaine for a longer period. There were no significant differences between the groups in albumin, ALT, and AST levels.



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  		Fig. 1. Percentages of cocaine addicts who did not relapse during a 1-year follow-up period as a function of index admission cholesterol level.

 

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  		TABLE 2. Total Cholesterol in Relapsing and Nonrelapsing Cocaine Addictsa
 
The mean (±SD) cholesterol level for the entire patient group was 159.80 ± 30.27 mg/dl. The cholesterol values of relapsers and nonrelapsers are shown in Table 2. Comparisons of these values by ANCOVAs with age and weight as covariates show significant differences between the two groups at 3 months, 6 months, and 1 year after discharge. At all time points, baseline cholesterol levels measured while patients were hospitalized were lower in those who subsequently relapsed than in those who remained abstinent.

Nineteen patients (59.4%) had a cholesterol concentration below 160 mg/dl. The time course of maintenance of a drug-free status in patients with cholesterol levels above or below 160 mg/dl is depicted in Figure 1. This figure shows that the relapse rate increased rapidly in the low cholesterol group during the first 6 months after discharge from the hospital and then stabilized. The relapse rate of patients in the higher cholesterol group increased during the first 3 months and stabilized later, but the percentage of relapsers was smaller. A comparison of the two survival curves performed with a Kaplan-Meier survival analysis revealed a significant difference (log rank test = 4.21, df = 1, p = .04).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
Diminished cholesterol levels have been repeatedly reported to be associated with a variety of psychiatric conditions. In this study of non–opiate-dependent and non–alcohol-dependent cocaine addicts, whose cholesterol levels had been determined once during their stay on an inpatient unit, relapsers were found to have cholesterol levels significantly lower than those of patients who did not relapse 3 months, 6 months, and 1 year after discharge. When patients were divided as a function of whether their cholesterol levels were above or below 160 mg/dl, the individuals in the low cholesterol group had a relapse rate that increased rapidly during the first 6 months after discharge and then stabilized. The relapse rate of patients in the higher cholesterol group increased during the first 3 months and stabilized later, but the percentage of relapsers was smaller. Biological variables might improve our ability to predict relapse. A review of recent literature on the topic of predictors of relapse in cocaine addicts indicates that there is no consensus about the nature of such predictors. Some investigators have reported that a high severity of psychiatric, family, or social problems or poor retention in treatment were associated with a decreased likelihood of achieving or maintaining abstinence (41–43), whereas others have not found any relationship between baseline social, demographic, and psychiatric variables and long-term outcome (44, 45).

Statistics computed by the Centers for Disease Control and Prevention, National Center for Health Statistics (National Health and Nutrition Examination Survey III), indicate that during the 1988 to 1994 period, total cholesterol values in the United States were 204 mg/dl in white males, 201 mg/dl in black males, and 206 mg/dl in males of different ethnic origin, aged 35 to 44 years. In the present study, which involved males in the same age range, the mean cholesterol values was 159 mg/dl. The percentage of patients who had a cholesterol below 160 mg/dl was high. This is in contrast with data obtained in the course of general population surveys, which show that percentages of individuals with cholesterol levels below 160 mg/dl vary from 4% to 10% (2–4, 10, 46). Reasons for the high percentage of low cholesterol concentrations among groups of substance abusers are unknown. Poor nutritional habits due in part to lack of appetite, lack of interest in food while "high," unwillingness to spend money for food instead of drugs, genetic predisposition, or other factors could play a role in these observations.

Mechanisms underlying the existence of associations between low cholesterol levels and psychopathology are unknown, but various explanations have been proposed. Cholesterol does not cross the blood-brain barrier, but a low cholesterol can be accompanied by a decrease in circulating levels of the serotonin (5-HT) precursor, the amino acid tryptophan, and by an increase in the branched-chain amino acids that compete with it for brain entry. A decrease in circulating tryptophan and an increase in competing amino acids result in a decreased synthesis of 5-HT because the brain enzyme that converts tryptophan to 5-HT is unsaturated. These amino acid changes have been observed in individuals who diet to lose weight and decrease carbohydrate and fat intake (47, 48). Dieting because of decreased appetite is frequently observed in depressed individuals and is accompanied by amino acid changes. Poor eating habits are also frequently observed in drug addicts. Tryptophan can be affected in another way. It circulates in a free form that crosses the blood-brain barrier and in a form bound to albumin that is believed not to cross the blood-brain barrier. A low cholesterol can be associated with a decrease in fatty acids (FAs) that also bind to albumin. When fewer FAs are bound, more albumin is available for binding to tryptophan. This results in a decrease in free tryptophan available for entry into the brain and in a decrease in central 5-HT.

Alternatively, it has been suggested that plasma total cholesterol may be a marker for changes in polyunsaturated fatty acids (PUFAs). According to Hibbeln and Salem (49), increased rates of depression, suicide, and violence found to be associated with a low cholesterol could be attributed instead to changes in long-chain PUFAs. Dietary advice given in an effort to lower serum cholesterol alters the composition of FAs consumed by replacing saturated fats by n-6 PUFAs (usually in the form of corn and soybean oil), thereby increasing the ratio of n-6 to n-3 PUFAs and lowering n-3 PUFAs in tissues. PUFAs cross the blood-brain barrier and play an important role in maintaining the functional and structural characteristics of neuronal membranes, where they are highly concentrated. There is evidence that an n-3 deficiency or an imbalance in the n-6/n-3 ratio could play a role in the pathophysiology of some psychiatric disorders.

The present study has methodological limitations. Cholesterol was measured only once, when patients were hospitalized. No measurement was obtained during the follow-up period. Still this sole measure was significantly associated with relapse risk. It should also be pointed out that we selected cocaine abusers whose alcohol consumption was nonexistent or moderate and who did not have abnormal results on liver function tests. Because excessive alcohol consumption and liver disease affect cholesterol metabolism, it is possible that our findings might not be generalized to groups of cocaine addicts who consume larger amounts of alcohol.

In conclusion, we observed that the percentage of individuals with cholesterol levels below 160 mg/dl was higher in a group of cocaine addicts than in subjects who had participated in general population surveys. We observed also an association between a low cholesterol and an increased relapse rate in a group of non–opiate-dependent and non–alcohol-dependent cocaine addicts. This finding needs to be replicated in larger patient samples. Future studies may then be needed to unravel the mechanisms underlying the relationship between low cholesterol levels and the rapid resumption of cocaine use after a period of detoxification.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
This study was supported by Grant DA-09648 from the National Institute on Drug Abuse.

Received for publication August 17, 2001.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

  1. Muldoon MF, Manuck SB, Mathews KA. Lowering cholesterol concentration and mortality: a quantitative review of primary prevention trials. BMJ 1990; 301: 309–14.
  2. Glueck CJ, Tieger M, Kunkel R, Hamer T, Tracy T, Speirs J. Hypocholesterolemia and affective disorders. Am J Med Sci 1994; 308: 218–25.[Medline]
  3. Morgan RE, Palinkas LA, Barrett-Connor EL, Wingard DL. Plasma cholesterol and depressive symptoms in older men. Lancet 1993; 341: 75–9.[CrossRef][Medline]
  4. Neaton JD, Blackburn H, Jacobs D, Kuller L, Lee DJ, Sherwin R, Shih J, Stamler J, Wentworth D. Serum cholesterol level and mortality findings for men screened in the Multiple Risk Factor Intervention Trial. Arch Intern Med 1992; 152: 1490–500.[Abstract/Free Full Text]
  5. Terao T, Yoshimura R, Ohmori O, Takano T, Takahashi N, Iwata N, Suzuki T, Abe K. Effect of serum cholesterol levels on meta-chlorophenylpiperazine-evoked neuroendocrine responses in healthy subjects. Biol Psychiatry 1997; 41: 974–8.[CrossRef][Medline]
  6. Steegmans PHA, Fekkes D, Hoes AW, Bak AAA, van der Does E, Diederick EG. Low serum cholesterol concentration and serotonin metabolism in men. BMJ 1996; 312: 221.[Free Full Text]
  7. Horsten M, Wamala SP, Vingerhoets A, Orth-Gomer K. Depressive symptoms, social support, and lipid profile in healthy middle-aged women. Psychosom Med 1997; 59: 521–8.[Abstract/Free Full Text]
  8. Suarez EC. Relations of trait depression and anxiety to low lipid and lipoprotein concentrations in healthy young adult women. Psychosom Med 1999; 61: 273–9.[Abstract/Free Full Text]
  9. Lindberg G, Rastam L, Gullberg B, Eklund GA. Low serum cholesterol concentration and short term mortality from injuries in men and women. BMJ 1992; 305: 277–9.
  10. Jacobs D, Blackburn H, Higgins M, Reed D, Iso H, McMillan G, Neaton J, Nelson J, Potter J, Rifkind B, Rossouw J, Shekelle R, Yusuf S. Report of the Conference on Low Blood Cholesterol: mortality association. Circulation 1992; 86: 1046–60.[Abstract/Free Full Text]
  11. Partonen T, Haukka J, Virtamo J, Taylor PR, Lonnqvist J. Association of low serum total cholesterol with major depression and suicide. Br J Psychiatry 1999; 175: 259–62.[Abstract/Free Full Text]
  12. Sullivan PF, Joyce PR, Bulik CM, Mulder RT, Oakley-Browne M. Total cholesterol and suicidality in depression. Biol Psychiatry 1994; 36: 472–7.[CrossRef][Medline]
  13. Alvarez JC, Cremniter D, Lesieur P, Gregoire A, Gilton A, Macquin-Mavier I, Jarreau C, Spreux-Varoquaux O. Low blood cholesterol and low platelet serotonin levels in violent suicide attempters. Biol Psychiatry 1999; 45: 1066–9.[CrossRef][Medline]
  14. Fawcett J, Busch KA, Jacobs D, Kravitz HM, Fogg L. Suicide: a four-pathway clinical-biochemical model. Ann N Y Acad Sci 1997; 836: 288–301.[Medline]
  15. Gallerani M, Manfredini R, Caracciolo S, Scapoli C, Molinari S, Fersini C. Serum cholesterol concentrations in parasuicide. BMJ 1995; 310: 1632–6.[Abstract/Free Full Text]
  16. Golier JA, Marzuk PM, Leon AC, Weiner C, Tardiff K. Low serum cholesterol level and attempted suicide. Am J Psychiatry 1995; 152: 419–23.[Abstract/Free Full Text]
  17. Kunugi H, Takei N, Aoki H, Shinichiro N. Low serum cholesterol in suicide attempters. Biol Psychiatry 1997; 41: 196–200.[CrossRef][Medline]
  18. Modai I, Valevski A, Dror S, Weizman A. Serum cholesterol levels and suicidal tendencies in psychiatric inpatients. J Clin Psychiatry 1994; 55: 252–4.[Medline]
  19. Sarchiapone M, Roy M, Camardese G, De Risio S. Further evidence for low serum cholesterol and suicidal behavior. J Affect Disord 2000; 61: 69–71.[CrossRef][Medline]
  20. Brown SL, Salive ME, Harris TB, Simonsick EM, Guralnik JM, Kohout FJ. Low cholesterol concentrations and severe depressive symptoms in elderly people. BMJ 1994; 308: 1328–32.[Abstract/Free Full Text]
  21. Markovitz JH, Smith D, Raczynski JM, Oberman A, Williams OD, Knox S, Jacobs DR Jr. Lack of relation of hostility, negative affect, and high-risk behavior with low plasma lipid levels in the Coronary Artery Risk Development in Young Adults Study. Arch Intern Med 1997; 157: 1953–9.[Abstract/Free Full Text]
  22. Pekkanen J, Nissinen A, Punsar S, Karvonen MJ. Serum cholesterol and risk of accidental or violent death in a 25-year follow-up. Arch Intern Med 1989; 149: 1589–91.[Abstract/Free Full Text]
  23. Weidner G, Connor SL, Hollis JF, Connor WE. Improvements in hostility and depression in relation to dietary change and cholesterol lowering. Ann Intern Med 1992; 117: 820–3.
  24. Chen Z, Peto R, Collins R, MacMahon S, Lu J, Li W. Serum cholesterol concentration and coronary heart disease in population with low cholesterol concentrations. BMJ 1991; 303: 276–82.
  25. Farchi G, Menotti A, Conti S. Coronary risk factors and survival probability from coronary and other causes of death. Am J Epidemiol 1987; 126: 400–8.[Abstract/Free Full Text]
  26. Smith GD, Shipley MJ, Marmot MG, Rose G. Plasma cholesterol concentration and mortality: the Whitehall study. JAMA 1992; 267: 70–6.[Abstract/Free Full Text]
  27. Virkkunen M. Serum cholesterol levels in homicidal offenders: a low cholesterol level is connected with a habitually violent tendency under the influence of alcohol. Neuropsychobiology 1983; 10: 65–9.[CrossRef][Medline]
  28. Virkkunen M. Serum cholesterol in antisocial personality. Neuropsychobiology 1979; 5: 27–30.[CrossRef][Medline]
  29. Freedman DS, Byers T, Barret DH, Stroup NE, Eaker E, Monroe-Blum H. Plasma lipid levels and psychologic characteristics in men. Am J Epidemiol 1995; 141: 507–17.[Abstract/Free Full Text]
  30. Virkkunen M, Penttinen H. Serum cholesterol in aggressive conduct disorder: a preliminary study. Biol Psychiatry 1984; 19: 435–9.[Medline]
  31. Hillbrand M, Spitz RT, Foster HG. Serum cholesterol and aggression in hospitalized male forensic patients. J Behav Med 1995; 18: 33–43.[CrossRef][Medline]
  32. Mufti RM, Balon R, Arfken CL. Low cholesterol and violence. Psychiatr Serv 1998; 49: 221–4.[Abstract/Free Full Text]
  33. Rao U, Carlson GA, Rapport MD. Serum cholesterol and aggressive behavior in psychiatrically hospitalized children. Acta Psychiatr Scand 1991; 83: 77–8.[Medline]
  34. Stewart MA, Stewart SG. Serum cholesterol in antisocial personality: a failure to replicate earlier findings. Neuropsychobiology 1981; 7: 9–11.[Medline]
  35. Ho WK, Wen HL, Fung KP, Ng YH, Au KK, Ma L. Comparison of plasma hormonal levels between heroin-addicted and normal subjects. Clin Chim Acta 1977; 75: 415–9.[CrossRef][Medline]
  36. Gettler JF. Hypocholesterolemia in substance abusers [letter]. South Med J 1991; 84: 937.[Medline]
  37. Maccari S, Bassi C, Zanoni P, Plancher AC. Plasma cholesterol and triglycerides in heroin addicts. Drug Alcohol Depend 1991; 29: 183–7.[CrossRef][Medline]
  38. Spitzer RL, Williams JB, Gibbon M, First MB. User’s guide for the Structured Clinical Interview of the DSM-III-R. Washington DC: American Psychiatric Press; 1990.
  39. McLellan AT, Kushner H, Metzger D, Peters R, Smith I, Grissom G, Pettinati H, Argeriou M. The fifth edition of the Addiction Severity Index. J Subst Abuse Treat 1992; 9: 199–213.[CrossRef][Medline]
  40. Kleinbaum DG. Survival analysis: a self-learning text. New York: Springer-Verlag; 1996.
  41. Simpson DD, Joe GW, Fletcher BW, Hubbard RL, Anglin MD. A national evaluation of treatment outcomes for cocaine dependence. Arch Gen Psychiatry 1999; 56: 507–14.[Abstract/Free Full Text]
  42. Pettinati HM, Pierce JD Jr, Belden PP, Meyers K. The relationship of axis II personality disorders to other known predictors of addiction treatment outcome. Am J Addict 1999; 8: 136–47.[CrossRef][Medline]
  43. McKay JR, Alterman AI, Mulvaney FD, Koppenhaver JM. Predicting proximal factors in cocaine relapse and near miss episodes: clinical and theoretical implications. Drug Alcohol Depend 1999; 56: 67–78.[CrossRef][Medline]
  44. McKay JR, Alterman AI, Cacciola JS, Mulvaney FD, O’Brien CP. Prognostic significance of antisocial personality disorder in cocaine-dependent patients entering continuing care. J Nerv Ment Dis 2000; 188: 287–96.[CrossRef][Medline]
  45. Alterman AI, McKay JR, Mulvaney FD, Cnaan A, Cacciola JS, Tourian KA, Rutherford MJ, Merikle EP. Baseline prediction of 7-month cocaine abstinence for cocaine dependence patients. Drug Alcohol Depend 2000; 59: 215–21.[CrossRef][Medline]
  46. Gartside PS, Glueck CJ. Relationship of dietary intake to hospital admission for coronary heart and vascular disease: the NHANES II national probability survey. J Am Coll Nutr 1993; 12: 676–84.[Abstract]
  47. Goodwin GM, Cowen PJ, Fairburn CG, Parry-Billings M, Calder PC, Newsholme EA. Plasma concentrations of tryptophan and dieting. BMJ 1990; 300: 1499–500.
  48. Anderson IM, Parry-Billings M, Newsholme EA, Fairburn CG, Cowen PJ. Dieting reduces plasma tryptophan and alters brain 5-HT function in women. Psychol Med 1990; 20: 785–91.[Medline]
  49. Hibbeln JR, Salem N Jr. Dietary polyunsaturated fatty acids and depression: when cholesterol does not satisfy. Am J Clin Nutr 1995; 62: 1–9.[Abstract/Free Full Text]



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