r e v a s s o c m e d b r a s . 2 0 1 3;5 9(4):360–367
Revista da
ASSOCIAÇÃO MÉDICA BRASILEIRA
www.ramb.org.br
Original article
Anxiety symptoms in crack cocaine and inhalant users
admitted to a psychiatric hospital in southern Brazil夽
Carlos Zubaran a,b,∗ , Katia Foresti c,d , Mariana Rossi Thorell e ,
Paulo Roberto Franceschini e
a
School of Medicine, University of Western Sydney, Sydney, Australia
Department of Psychiatry, Blacktown Hospital, Sydney West Area Health Service, Sydney, Australia
c School of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
d Department of Psychiatry, Western Sydney Local Health District, Sydney, Australia
e Hospital Santa Casa de Misericórdia, Porto Alegre, RS, Brazil
b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: The occurrence of psychiatric comorbidity among individuals with crack or
Received 28 September 2012
inhalant dependence is frequently observed. The objective of this study was to investigate
Accepted 23 January 2013
anxiety symptoms among crack cocaine and inhalant users in southern Brazil.
Available online 11 July 2013
Methods: The study investigated two groups of volunteers of equal size (n = 50): one group
consisted of crack cocaine users, and the other group consisted of inhalant users. Research
Keywords:
volunteers completed the Portuguese versions of the State-Trait Anxiety Inventory (STAI),
Crack cocaine
Hamilton Anxiety Rating Scale (HAM-A), and Self-Report Questionnaire (SRQ).
Solvents
Results: Both crack and inhalant users experience significant symptoms of anxiety. Inhalant
Anxiety
users presented significantly more anxiety symptoms than crack users according to the
Brazil
HAM-A questionnaire only. In contrast to the results of the HAM-A, the STAI failed to
Questionnaires
demonstrate a significant difference between the two groups of substance users. SRQ scores
revealed that crack and inhalants users had significant degrees of morbidity.
Conclusion: A significant difference regarding anxiety symptomatology, especially state
anxiety, was observed among inhalant and crack users. Anxiety and overall mental
psychopathology were significantly correlated in this sample. The results indicate that
screening initiatives to detect anxiety and additional psychiatric comorbidities among crack
and inhalant users are feasible and relevant.
© 2013 Elsevier Editora Ltda. All rights reserved.
Sintomas de ansiedade em usuários de crack e inalantes admitidos
em uma unidade psiquiátrica na Região Sul do Brasil
r e s u m o
Palavras-chave:
Objetivo: Investigar sintomas de ansiedade em usuários de crack e inalantes no Sul do Brasil.
Crack
Métodos: O estudo investigou dois grupos de voluntários com o mesmo número de indivíduos
Solventes
(n = 50): um grupo consistiu de usuários de crack e o outro grupo, de usuários de inalantes.
Study conducted at Universidade de Caxias do Sul and Clínica Paulo Guedes, Caxias do Sul, RS, Brazil.
Corresponding author.
E-mail: zubaran jr@yahoo.com (C. Zubaran).
0104-4230/$ – see front matter © 2013 Elsevier Editora Ltda. All rights reserved.
http://dx.doi.org/10.1016/j.ramb.2013.01.008
夽
∗
r e v a s s o c m e d b r a s . 2 0 1 3;5 9(4):360–367
Ansiedade
361
Os voluntários da pesquisa completaram as versões em português das escalas de ansiedade
Brasil
State-Trais Anxiety Inventory (STAI) e Hamilton Anxiety Rating Scale (HAM-A), e o Questionário
Questionários
de Autoavaliação (SRQ).
Resultados:
Ambos os grupos apresentaram sintomas significativos de ansiedade. Os
usuários de inalantes apresentaram escores quanto a HAM-A significativamente superiores
aos usuários de crack. Ansiedade e psicopatologia geral se apresentaram significativamente
correlacionados.
Conclusão: Sintomas de ansiedade são frequentes entre usuários de crack e inalantes. Um
processo de triagem de sintomas de ansiedade entre usuários de crack e inalantes deve
facilitar ainda mais as intervenções terapêuticas nesta área.
© 2013 Elsevier Editora Ltda. Todos os direitos reservados.
Introduction
Crack and inhalant abuse have been documented as two of the
most common addictive disorders in Brazil.1,2 Crack cocaine
and inhalants have been used in Brazil by street children,3
undergraduates,4 and medical students.5,6 Inhalants abuse
and dependence negatively affect youth regardless of gender,
ethnicity, age, and family income.7 The association between
inhalant dependence and other psychiatric morbidities is
higher than in patients with dependence to other psychoactive drugs, including alcohol.8
The co-occurrence of mood and anxiety disorders has been
predominantly associated with adverse outcomes among
young substance users.9 The prevalence figures of anxiety
disorders among substance users vary according to different studies.10 In the Drug Abuse Treatment Outcome Study
(DATOS), which assessed over 10,000 substance users, the
prevalence of generalized anxiety disorder (GAD) ranged from
2.2% to 4.2%,11 while in studies with smaller sample sizes the
prevalence rates of anxiety disorders varied substantially.12–14
Symptoms of anxiety were also the most common psychiatric
manifestation among adolescents with substance use-related
disorders (60% of both boys and girls).15 The significant association between any anxiety disorder and lifetime cocaine use
has been consistently detected in an independent survey conducted in the US and Canada.16 In a Spanish cross-sectional
study, nearly 42.5% of cocaine users recruited in non-clinical
settings presented with a psychiatric comorbidity; anxiety
disorders (13%) were the second most common comorbid
disorder, after depression.17 Data from an international multicenter study revealed that the onset of anxiety disorders
usually precedes the initiation of substance use disorders.18
The use of cocaine may precipitate panic attacks, phobia
reactions, obsessions, and compulsions, which may persist
after discontinuation of use.19,20 The comorbidity between
cocaine use and social phobia21 and post-traumatic stress
disorder (PTSD)22,23 tends to occur among individuals with
severe cocaine use, with personal background and family
history of psychiatric disorders.24 The association between
anxiety disorder and cocaine use has been described in the
context of affective disorder,25,26 and documented extensively
among people with panic attacks.27–29 Treatment-seeking
cocaine users also report significant levels of anxiety.14 Anxiety and mood disorders were the most common comorbid
Axis I disorders diagnosed in a sample of male inpatients in
Iowa.30 Anxiety is also a prominent clinical feature during the
abstinence phase of cocaine withdrawal.31 In comparison with
users of heroin only, users of both heroin and cocaine present
significantly more symptoms of anxiety.32 Anxiety has also
been considered as a risk factor for the occurrence of cocaineinduced paranoia.33
Anxiety disorders are commonly associated with inhalant
use. The reported prevalence rate of generalized anxiety disorder among inhalant users is 20.5%.8 Data from a national
epidemiological survey revealed that inhalant users had a
significant lifetime prevalence of anxiety disorders (36%).34
Female inhalant users presented higher lifetime prevalence
rates of any anxiety disorder in comparison with male users
(53% versus 30%), including panic disorder without agoraphobia (25% versus 11%), and specific phobia (28% versus
14%). Female inhalant users also were more likely to have
met the criteria for three or more anxiety disorders (15%
versus 8%) in the past year.34 In addition, adolescents with
inhalant abuse or dependence are significantly more likely to
have abuse or dependence of alcohol, hallucinogens, nicotine,
cocaine, and/or amphetamines, and are more likely to have
attempted suicide compared with other adolescent patients
who reported never using inhalants.35 Toluene is the main
component of inhalants used by youth in Brazil, including
homeless youth, as confirmed by urinary levels of hippuric
acid.36,37
Considering the frequent occurrence of psychiatric comorbidity among individuals with crack or inhalant dependence,
as well as the compounding and detrimental effects of this
association, it is essential to carefully screen these drug
users for anxiety.35,38 Furthermore, the majority of individuals
affected by anxiety disorders have never obtained effective
treatment despite the significant level of disability imposed by
these conditions.39 The objective of this study was to investigate anxiety symptoms among crack cocaine and inhalant
users in southern Brazil. To the authors’ knowledge, this is
the first time that crack and inhalant users have been simultaneously assessed with two anxiety-specific measures in
southern Brazil.
Methods
Sample
The study investigated two groups of volunteers of equal size
(n = 50): one group consisted of crack cocaine users and the
other group consisted of inhalant users. Both groups were
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r e v a s s o c m e d b r a s . 2 0 1 3;5 9(4):360–367
interviewed as inpatient volunteers in wards of a tertiary care
mental health facility and a higher education training site
associated with the Universidade de Caxias do Sul. Drug users
fulfilled the Diagnostic and Statistic Manual of Mental Disorders, 4th edition (DSM-IV) diagnostic criteria for crack cocaine
or inhalant dependence, according to a psychiatric interview
conducted upon admission by psychiatrists who were completely unfamiliar with this research protocol. Patients with
polydrug dependence had to satisfy the inclusion criteria of
using either crack cocaine or any type of inhalant drug as (a)
the main addictive substance, and (b) the one causing the most
salient dependence.
All patients who volunteered to participate in this investigation were assisted via the Brazilian public health system.
Taking into account that a substantial fraction of the sample was illiterate or semi-illiterate, all drug users completed
the questionnaires under minimal guidance by trained interviewers, who followed standardized instructional procedures.
Uncompleted or inappropriately completed questionnaires
were excluded from analysis. All volunteers spoke Portuguese
as their first language.
Informed consent and recruitment
This study was endorsed by the institutional Ethics and
Research Committees of the Universidade de Caxias do
Sul (UCS), which regulate all scientific activities at UCS.
All volunteers signed a informed consent. A certificate of
confidentiality was guaranteed to all research participants.
Consent from parents or legally responsible adults was
obtained before minor participants were formally enrolled in
the present study. All respondents were treated anonymously.
Research participants were recruited via word-of-mouth. Drug
users were approached to participate in this study after having
achieved a stable clinical course, as determined by their own
physician. The recruitment process took place during various
consecutive months, according to the rate of hospital admissions of prospective participants. Research participants were
interviewed only once for the purpose of this investigation.
Research tools
The State-Trait Anxiety Inventory (STAI) is one of the most
widely used self-report measures of anxiety in clinical and
research settings.40 The STAI measures two different components: state anxiety, which refers to a transitory and subjective
emotional state that varies over time; and trait anxiety, which
refers to a relatively stable pattern of reaction to stress with
anxiety and a tendency to perceive situations as threatening.41
The Portuguese version of the STAI was validated in a sample
of university students in Brazil.42 Each part varies from 20 to
80 points, and the scores indicate low (0–30), medium (31–49),
or high (50 or more) anxiety levels.41
The Hamilton Anxiety Rating Scale (HAM-A) was conceived
as an easy-to-use instrument to measure state anxiety.43 The
HAM-A has been used extensively to investigate symptoms of
anxiety as well as the result of interventions aimed at reducing levels of anxiety.44 The Portuguese version of the HAM-A
has been widely used for measuring mainly state anxiety.45
A score of 17 or below indicates absence of or low levels of
anxiety; a score from 18 to 24 indicates low to moderate anxiety levels; while a score from 25 to 30 indicates moderate to
severe anxiety levels.46
The Self-Reporting Questionnaire (SRQ) was used to identify minor and general psychiatric morbidity.47 The SRQ was
derived from research instruments used by the World Health
Organization (WHO) for studying psychiatric morbidity in primary care settings in developing countries.48,49 According to
SRQ, respondents were classified as high (≥ 8) or low (≤ 7)
scorers.50
The socio-economic status (SES) of research participants
was assessed via a scale previously tested in Brazil.51 This
instrument classifies SES into six categories: lower-lower,
upper-lower, lower-middle, upper-middle, lower-upper, and
upper-upper class.
Statistical analyses
Analysis of demographic variables was performed in relation to age and socioeconomic status. The overall scores of
the HAM-A, STAI, and SRQ were computed and subsequently
transformed into Z-scores for correlation and regression analyses. Student’s t-test for independent samples was performed
to examine differences between two groups of drug users.
Analyses of correlation via Pearson’s product-moment and
Spearman’s rank coefficients were computed between the
questionnaires’ scores and categories, respectively. Logistic
regression analyses were also conducted to explore predictive
effects of anxiety scales (HAM-A and STAI) on general psychopathology (SRQ). Statistical analyses were conducted using
the Statistical Package for Social Sciences (SPSS® ).
Results
Demographic data
The mean age in the overall sample was 20.2 years of age. The
mean ages in the groups of crack users and inhalant users
were 22.8 and 17.3 years of age, respectively. Regarding gender, the overall sample had 12% and 88% of female and male
volunteers, respectively. Table 1 shows a summary of all demographic information.
Regarding SES, most of the total sample was classified
as upper-lower class (30%) and lower-middle class (59%). A
nonparametric analysis via Kruskal-Wallis test of the two
subgroups differentiated according to SES strata revealed an
absence of a significant difference in the medians between the
two groups, with 2 (1, n = 100) = 2.15, p = 0.142.
Anxiety
The mean scores of the both anxiety rating scales used in
this study (HAM-A and STAI), in the combined sample of
crack and inhalant users and in each separate group are
shown in Table 2. According to the HAM-A classification,
71.7% of the sample did not have or had low levels of anxiety, while 28.3% presented anxiety. Considering each group
separately, crack users and inhalants users presented the following results, respectively: 90% and 53.1% (absence or low
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r e v a s s o c m e d b r a s . 2 0 1 3;5 9(4):360–367
Table 1 – Sociodemographic characteristics of the total sample of substance users
Sociodemographic characteristics
Total (n = 100)
Crack (n = 50)
Inhalant (n = 50)
Age
Mean (± SD)
Range
20.1 (6.2)
29 (11-40)
22.8 (6.4)
17 (11-28)
17.3 (4.5)
25 (15-40)
Gender
Male
Female
88
12
43 (86%)
7 (14%)
45 (90%)
5 (10%)
Socio-economic status
Lower-lower
Upper-lower
Lower-middle
Middle
3
32
57
8
1 (2%)
15 (30%)
28 (56%)
6 (12%)
2 (4%)
17 (34%)
29 (58%)
2 (4%)
levels of anxiety), and 10% and 46.9% (presence of anxiety).
Among crack users who experienced anxiety, 4% presented
light to moderate levels of anxiety, while 6% presented moderate to severe levels of anxiety. Among inhalant users who
experienced anxiety, 28.6% reported light to moderate levels
of anxiety, while 18.4% presented moderate to severe levels of
anxiety.
The STAI classified crack and inhalant users, in terms of
presence or absence of anxiety, taken together, as follows: 9%
(absence or low levels of anxiety) and 91% (presence of anxiety). The distribution according to the presence or absence
of anxiety as classified by the STAI in the groups of crack
and inhalant users, respectively, was as follows: 14% and 4%
(absence or low levels of anxiety), and 86% and 96% (presence of anxiety). Among crack users who experienced anxiety,
72% presented medium levels of anxiety, while 14% presented
high levels of anxiety. Among inhalant users who experienced
anxiety, 78% reported medium levels of anxiety, while 18%
presented high levels of anxiety.
A parametrical analysis using Student’s t-test for independent samples revealed a significant statistical difference
between the two groups of drug users according to the scores
of the HAM-A anxiety ratings scale: t (97) = −4.62, p < 0.001.
A nonparametric analysis using the Mann-Whitney test of
HAM-A scores according to a categorical distinction (absence
or presence of anxiety, based on a cut-off point of > 17, as
explained in the Methods section) also revealed a significant
difference among the groups of crack and inhalant users, with
z = −4.06, p < 0.001. This significant difference persisted when
the three different categories of intensity were taken into
account (z = −3.9, p < 0.001).
A parametrical analysis using Student’s t-test for independent samples revealed an absence of significant statistical
difference between the two groups of drug users according to
the STAI scores: t (98) = -1.54, p = 0.13. A nonparametric analysis using the Mann-Whitney test of STAI scores according to a
categorical distinction (absence or presence of anxiety, based
on a cut-off point of ≥ 31, as explained in the Methods section)
also revealed an absence of significant difference between the
groups of crack and inhalant users, with z = −1.74, p = 0.8. The
absence of significant difference persisted when the different
categories of intensity were analyzed (z = −1.37, p = 0.17).
Correlation analyses
Pearson product-moment correlation coefficients were computed among the overall scores of all questionnaires
completed by the three groups. The Bonferroni method was
used to control for type I error for all pair wise comparisons:
␣PC = 0.05/3 = 0.17.
A significant correlation was found between the scores of
the HAM-A and the scores of the STAI in the combined sample
of drug users (r = 0.43, p < 0.001). Spearman’s rank correlation
analysis also revealed a significant association between the
caseness (presence or absence of anxiety) generated by the
HAM-A and the STAI ( = 2; p < 0.05).
Significant correlations were also found between the scores
of HAM-A and SRQ (r = 0.44, p < 0.001) and between the scores
of STAI and SRQ (r = 0.67, p < 0.001).
Linear regression analyses
Bivariate linear regression analyses were conducted, separately, to evaluate the prediction of general psychopathology
scores (SRQ) according to the scores of the anxiety rating scales
among crack and inhalant users.
Table 2 – Scores and case details of crack and inhalants users according to the HAM-A and the STAI questionnaires
HAM-A
Mean (SD)
Crack (n = 50)
Inhalant (n = 50)
Both groups
8.38 (8.07)
16.45 (9.28)
12.37 (9.54)
Absence/low levels
of anxiety (%)
90
53.1
71.7
STAI
Presence of
anxiety (%)
10
46.9
28.3
HAM-A, Hamilton Anxiety Rating Scale; STAI, State-Trait Anxiety Inventory.
Mean (SD)
48.06 (10.52)
51 (8.39)
49.53 (9.58)
Absence/low levels
of anxiety (%)
14
4
9
Presence of
anxiety (%)
86
96
91
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Discussion
3
2
SRQ
1
0
–1
R Sq Linear = 0.447
–2
–3
–2
–1
0
2
1
3
STAI
3
2
SRQ
1
0
–1
R Sq Linear = 0.244
–2
–2
–1
1
0
2
3
HAM-A
Fig. 1 – Scatter plots demonstrating the linear correlation
between the SRQ (general psychopathology) and the STAI
and HAM-A (anxiety) questionnaires.
SRQ, Self-Report Questionnaire; STAI, State-Trait Anxiety
Inventory; HAM-A; Hamilton Anxiety Rating Scale.
An initial analysis to predict changes in the SRQ scores,
having the HAM-A scores as a predictor, revealed that the
two variables were linearly related, such that as the overall
anxiety symptomatology increases, the magnitude of general psychopathology also increases. The linear predictive
ability was significant (95% CI: 0.32-0.67). Approximately 24%
of the variance of the SRQ scores was accounted for by its
linear relationship with the HAM-A. A similar linear regression analysis was conducted to evaluate the prediction of
the SRQ scores using the STAI scores as a predictor. The
results indicated that the SRQ scores and the STAI scores
are also linearly related. The correlation was significant (95%
CI: 0.52-0.82). Approximately 45% of the variance of the SRQ
score was accounted for by its linear relationship with the
STAI.
The scatter plots of the two bivariate linear regression analyses mentioned above are presented in Fig. 1.
The results presented in this study indicate that both crack
and inhalant users experience significant symptoms of anxiety. The prevalence of anxiety among crack users varies from
10% (HAM-A) to 86% (STAI), while among inhalant users the
figures vary from 46.9% (HAM-A) to 96% (STAI). Crack users
presented significantly more anxiety symptoms than inhalant
users according to the HAM-A questionnaire only. This difference was observed when results were treated parametrically
and non-parametrically. These findings are consistent with
results obtained by other studies, which revealed that anxiety
is, among other psychiatric symptoms, a frequent comorbidity among crack cocaine users.17 Crack cocaine users, in
particular, are known to present with significant psychiatric
comorbidities, including depression, anxiety disorders, bipolar disorder, and attention-deficit/hyperactivity disorder, with
eventual fatal outcomes.52,53 In Brazil, treatment-seeking nonintravenous cocaine users presented a lifetime prevalence
of Axis I or Axis II disorders of 69%, and anxiety disorders were the most common psychiatric disorder (31%).54
The higher prevalence of anxiety disorders among cocaine
dependent subjects encompasses different dysfunctions such
as general anxiety, phobic, panic, and obsessive-compulsive
disorders.55 Although the physiological and psychoactive
effects of cocaine are similar regardless of its hydrochloride
or crack form, evidence indicates a greater abuse liability and
propensity for dependence, as well as more severe consequences, when cocaine is smoked or injected intravenously
in comparison with intranasal use.56 In Brazil, a significant
tendency to change routes of administration and patterns of
cocaine use has been documented by several studies in the
last decade.1,44,57–60
Contrarily to the results of the HAM-A, the STAI failed
to demonstrate a significant difference between the two
groups of substance users. There are conceptual differences
between the two scales used to evaluate anxiety in this
sample. The HAM-A measures state anxiety, which is a symptomatic expression, while the STAI also captures trait anxiety,
which is related to characteriological issues.45 The differences
between “state” and “trait” anxiety reflect the conceptual distinction between existing anxiety as a transitory state and the
anxiety as a relatively stable personality characteristic.61,62
STAI scores may suffer from being influenced by different
illness variables, such as severity, chronicity, and comorbidity of symptoms.63 Although variations in ratings have been
reported with the HAM-A as well,64,65 the STAI was unable to
distinguish between anxiety and depression in a mixed group
of patients with both conditions, from which the authors concluded that the STAI does have clinical utility for measuring
emotional distress.63 In the present study, only the trait subset
of the STAI was used. The results of this study suggest therefore that trait anxiety is not significantly affected by crack and
inhalant use, and that only measures of state anxiety should
be used for the assessment of anxiety related to cocaine and
inhalant use.
Considering the contrasting results produced by different scales used to measure anxiety, there is an increased
need to investigate possible differences in the symptomatic
r e v a s s o c m e d b r a s . 2 0 1 3;5 9(4):360–367
measurement among patients with anxiety.63 Although psychometric measures have been produced extensively in
psychiatry, sometimes via a single assessment tool, it has
been advocated that anxiety and depression may be similar
elements of a general psychological distress experience of difficult differentiation.66 Likewise, depression is a disorder with
important clinical significance among crack cocaine users. A
previous study detected a lifetime prevalence of 17.8% for
depression among crack cocaine users.67 Prevalence of depression among crack users is believed to be higher than what has
been previously reported.68 Furthermore, studies that investigated depressive disorders among crack users have detected
additional psychiatric comorbidities, including anxiety, bipolar disorder, and attention-deficit/hyperactivity disorder, with
eventual fatal outcomes.52,53
Regarding psychiatric morbidity, the scores generated by
the SRQ revealed that crack and inhalants users had significant degrees of morbidity. The SRQ has been previously used
as general screening tool for mental disorders in the context
of substance abuse.69–72 Furthermore, in a community-based
study conducted in southern Brazil, in which 126 adolescents were screened for mental problems, the prevalence
of depressive symptoms, suicidal ideation, and hopelessness
were higher among those who were detected as SRQ-positive
according to a cut-off score of ≥ 8,73 the same threshold used
in the present study.
The results of Pearson correlation analyses also revealed a
significant correlation among anxiety symptoms and general
psychopathology, which attest to a congruent measurement
of the constructs investigated in this study. Furthermore,
the results of the bivariate linear regression analyses also
revealed that the scores of the two anxiety rating scales
used in this study can predict, with significant accuracy,
the scores of general psychopathology of crack and inhalant
users.
Previous evidence, based on regression analyses of data
from a national survey in the United States, revealed that
inhalant users had greater odds of intravenous drug use
than users who had not used inhalants.34 The results presented here reveal a direct and predictive association between
depressive symptoms and general mental disorder among
crack and inhalant users. Although additional studies are
required to further substantiate these findings, these results
may recommend more rigorous and extensive screening
efforts to detect and treat depressive symptoms among crack
and inhalant users.
This study may present some limitations, especially in relation to the nature of the sample investigated. Some of these
discrepancies were revealed in the analyses of demographic
data. Firstly, regarding age range, inhalant users presented
a lower mean age in comparison with crack users. The reasons for the early age of inhalant use are based on the
fact that many organic solvents are present in wide array
of chemical compounds publicly commercialized for a broad
variety of household purposes, which facilitate children’s
access. In fact, inhalant use has been characterized as preferentially prevalent among children and juveniles in both
developed and developing economies.74–79 In Brazil, as well
as in other developing countries, inhalants tend to be the
preferred drug used among the street children, who are who
365
live and wander unsupervised on the streets of major urban
centers.80
Secondly, male participants predominated significantly in
both groups. Evidence based on a series of surveys conducted
with Brazilian secondary school students demonstrated an
increased use of illicit psychotropic drugs by males, while
women prefer to use drugs in the form of pills, such as anxiolytics and amphetamines.81
Thirdly, the psychometric tools used in this study were not
specifically designed to evaluate adolescents. Although the
mean age in the overall sample was 20.1 years, the mean age
of inhalant users was 17.3 years. Nevertheless, most of the
instruments used in this study have been tested previously
as screening tools among adolescents in southern Brazil.73
Furthermore, the unavailability of versions validated in Portuguese of instruments developed specifically for assessing
adolescents’ mental health prevented, at this stage, the use
of a more suitable methodology for this sample. This limitation highlights the need for validation studies of psychometric
instruments among adolescents in Brazil.
Despite the above-mentioned limitations, the sample
investigated in this study was recruited in public health facilities, where members of all socio-economic strata of the
Brazilian society have prompt access to health care. This
advantage is particularly relevant in the case of a study conducted in a developing economy, where inequalities of care
are known to produce significant health differentials.82
Conclusion
A significant difference regarding anxiety symptomatology,
especially state anxiety, was observed among inhalant and
crack users. Anxiety and overall mental psychopathology were
significantly correlated in this sample. The results indicate
that screening initiatives to detect anxiety and additional psychiatric comorbidities among crack and inhalant users are
feasible and relevant. Considering that drug abuse, especially
of inhalants, affect youth preferentially, and that adolescence
is a vulnerable life cycle phase, the present findings justify
more rigorous and extensive screening efforts to detect and
treat anxiety disorders among crack cocaine and inhalant
users.
Conflicts of interest
The authors declare no conflicts of interest.
Acknowledgements
The authors acknowledge the contribution of several students
in the research group during the initial phases of this investigation.
This study was partially supported by grant No. 00060525.00/03-8 from the Science and Technology State Agency, Rio
Grande do Sul, Brazil.
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