BMJ  2006;332:803-804 (8 April), doi:10.1136/bmj.332.7545.803

Editorial

Ecstasy and the antecedents of illicit drug use

Anxiety and depression may be risk factors for using ecstasy

Ecstasy (3-4 methylenedioxymethamphetamine, MDMA) is a synthetic, psychoactive drug chemically similar to the stimulant methamphetamine and the hallucinogen mescaline. It is neurotoxic for animals and a health risk for humans.¹ Most users are young, and use has increased in most European countries where annual survey data are available, now exceeding amphetamine use in some. In Europe recent lifetime experience rates range from 0.4% to 13% among 15-24-year olds; in the United States the rate is 14.8% among 18-25 year olds.² However, surveys probably underestimate the number of users.³ Ecstasy users often use other illicit drugs,⁴ raising the question why young people take addictive drugs.

To become addicted to something, you must first be able to obtain it; then you have to try it, you must instantly like it or learn to like it, you must start to think that you need it, and you must like the rewards more than you dislike the punishments. Late childhood and early adolescence is the most dangerous time, when contacts outside the family increase and socialising with friends becomes more important. Peers and pushers can encourage experimentation with drugs, and experienced users may teach and encourage continued use. Those with mental health problems may be at increased risk of regular use and addiction. Emotional and behavioural problems have repeatedly been found to be associated with and to predict substance misuse.^{5 6} Children with such problems tend to be impulsive, hyperactive, aggressive, and delinquent; have short attention spans; and resort to truancy and antisocial behaviour.

However, young people with anxiety or depression tend to have fewer friends and social contacts than their normally developing peers and are therefore less often exposed to drug use in adolescent subcultures. Many studies have found no association between these disorders and later risk of illicit drug use or addiction. Now, however, Huizink and colleagues report that Dutch adolescents with symptoms of anxiety or depression in childhood are at increased risk of using ecstasy (p 825).⁷ As they note, ecstasy may be especially appealing to young people with anxiety or depression because it can cause feelings of relaxation, euphoria, and friendship. This "love drug" may appeal to a youth group that would otherwise be less interested in drug use.

Causal influences in drug use are notoriously difficult to identify because cohort studies are burdensome and there are three possible explanations for any association: mood disorders can lead to drug misuse, drug misuse can lead to mood disorders, or both can have a common cause. The third possibility is suggested by twin and adoption studies that show familial clustering of drug use, which could be explained by genetic and environmental factors.^{6 8} In Huizink and colleagues' study the fortuitous absence of ecstasy from the Dutch drug scene at the time of the baseline examination of behavioural and emotional problems supports the view that anxiety and depression can encourage subsequent ecstasy use.⁷ Their results thus identify one causal path, but there was also a hint of a second path: delinquent behaviour predicted ecstasy use in the multivariate analysis with all available confounders, but this association disappeared in the final analysis.

It should be noted, however, that only 10% of those with symptoms of anxiety and depression in this Dutch study had five or more occasions of ecstasy use, and the resulting hazard ratio was only 2.22. Studies of substance misuse typically identify many risk factors, but no single dominant one. We cannot solve the problems of drug misuse by eliminating a single risk factor. Preventive efforts must be target many factors. Educational interventions in school are popular, but a recent Cochrane review found only one skills oriented programme that reduced hard drug use.⁹ Unfortunately, ecstasy users often are well aware of the risks of drug use, but do not think themselves to be vulnerable.¹⁰ Prevention should start early. Randomised controlled studies have found that teaching of good parenting skills in early childhood is effective.¹¹ Good mental health services for children also seem important: one US study found that many adolescents entering treatment programmes for substance misuse had untreated mental health problems.¹²

Finnish Foundation for Alcohol Studies, PO Box 220, FIN-00531, Helsinki, Finland
(kari.poikolainen{at}stakes.fi)

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Research p 825

Competing interests: None declared.

References

1. McCann UD, Szabo Z, Scheffel U, Dannals RF, Ricaurte GA. Positron emission tomographic evidence of toxic effect of MDMA ("Ecstasy") on brain serotonin neurons in human beings. Lancet 1998;352: 1433-7.[CrossRef][ISI][Medline]
2. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Annual report 2005: the state of the drugs problem in Europe. http://ar2005.emcdda.eu.int/en/page001-en.html (accessed 28 Jan 2006).
3. Morral AR, McCaffrey DF, Chien S. Measurement of adolescent drug use. J Psychoactive Drugs 2003;35: 301-9.[Medline]
4. Yacoubian GS Jr. Correlates of ecstasy use among tenth graders surveyed through monitoring the future. J Psychoactive Drugs 2002;34: 225-30.[Medline]
5. Poikolainen K. Antecedents of substance use in adolescence. Curr Opin Psychiatry 2002;15: 241-5.[CrossRef]
6. Compton WM, Thomas YF, Conway KP, Colliver JD. Developments in the epidemiology of drug use and drug use disorders. Am J Psychiatry 2005;162: 1494-502.[Abstract/Free Full Text]
7. Huizink AC, Ferdinand RF, van der Ende J, Verhulst FC. Symptoms of anxiety and depression in childhood and use of MDMA: prospective population based study. BMJ 2006;332: 825-7.[Abstract/Free Full Text]
8. Kendler KS, Jacobson KC, Prescott CA, Neale MC. Specificity of genetic and environmental risk factors for use and abuse/dependence of cannabis, cocaine, hallucinogens, sedatives, stimulants, and opiates in male twins. Am J Psychiatry 2003;160: 687-95.[Abstract/Free Full Text]
9. Faggiano F, Vigna-Taglianti F, Versino E, Zambon A, Borraccino A, Lemma P. School-based prevention for illicit drugs' use. Cochrane Database Syst Rev 2005;(2): CD003020
10. Gamma A, Jerome L, Liechti ME, Sumnall HR. Is ecstasy perceived to be safe? A critical survey. Drug Alcohol Depend 2005;77: 185-93.[CrossRef][ISI][Medline]
11. Scott S, Spender Q, Doolan M, Jacobs B, Aspland H. Multicentre controlled trial of parenting groups for childhood antisocial behaviour in clinical practice. BMJ 2001;323: 194-8.[Abstract/Free Full Text]
12. Jaycox LH, Morral AR, Juvonen J. Mental health and medical problems and service use among adolescent substance users. Am Acad Child Adolesc Psychiatry 2003;42: 701-9.[Medline]

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