Background The extent to which adult height, a biomarker of the interplay of genetic endowment and early-life experiences, is related to risk of chronic diseases in adulthood is uncertain.
Methods We calculated hazard ratios (HRs) for height, assessed in increments of 6.5 cm, using individual–participant data on 174 374 deaths or major non-fatal vascular outcomes recorded among 1 085 949 people in 121 prospective studies.
Results For people born between 1900 and 1960, mean adult height increased 0.5–1 cm with each successive decade of birth. After adjustment for age, sex, smoking and year of birth, HRs per 6.5 cm greater height were 0.97 (95% confidence interval: 0.96–0.99) for death from any cause, 0.94 (0.93–0.96) for death from vascular causes, 1.04 (1.03–1.06) for death from cancer and 0.92 (0.90–0.94) for death from other causes. Height was negatively associated with death from coronary disease, stroke subtypes, heart failure, stomach and oral cancers, chronic obstructive pulmonary disease, mental disorders, liver disease and external causes. In contrast, height was positively associated with death from ruptured aortic aneurysm, pulmonary embolism, melanoma and cancers of the pancreas, endocrine and nervous systems, ovary, breast, prostate, colorectum, blood and lung. HRs per 6.5 cm greater height ranged from 1.26 (1.12–1.42) for risk of melanoma death to 0.84 (0.80–0.89) for risk of death from chronic obstructive pulmonary disease. HRs were not appreciably altered after further adjustment for adiposity, blood pressure, lipids, inflammation biomarkers, diabetes mellitus, alcohol consumption or socio-economic indicators.
Conclusion Adult height has directionally opposing relationships with risk of death from several different major causes of chronic diseases.
Height; cardiovascular disease; cancer; cause-specific mortality; epidemiological study; meta-analysis
Neoadjuvant radiation therapy (RT) has several theoretical benefits in the treatment of retroperitoneal sarcoma (RPS), but concerns remain about treatment toxicity and perioperative morbidity. There are limited data regarding its effect on perioperative outcomes, most of which come from small, single-institution series. The purpose of this study was to evaluate the short-term (30-day) postoperative morbidity and mortality associated with neoadjuvant RT following resection of RPS.
The 2005–2011 National Surgical Quality Improvement Program Participant User File was queried for patients undergoing RPS resection. Subjects were stratified by use of neoadjuvant RT. Perioperative variables and short-term 30-day outcomes were compared. Groups were then propensity matched using a 2:1 nearest-neighbor algorithm and multivariable logistic regression was performed to assess neoadjuvant RT as a predictor of short-term 30-day outcomes.
A total of 785 patients were identified. Neoadjuvant RT was administered to 71 (9.0%). Patients who received neoadjuvant RT were slightly younger (56 vs. 62 years, p < 0.001), but otherwise the groups were similar. After propensity matching, all baseline characteristics were highly similar. Median operative time was longer in the neoadjuvant RT group (279 vs. 219 min, p < 0.01), but there were no differences in mortality (1.4 vs. 2.1%, p = 0.71), major complications (28.2 vs. 25.2%, p = 0.69), overall complications (35.2 vs.33.2%, p = 0.83), early reoperation (5.6 vs. 7.4%, p = 0.81), or length of stay (7 vs. 7 days, p = 0.56). Following further adjustment with logistic regression, we confirmed that there were no differences in 30-day mortality or morbidity between patients who did and did not receive neoadjuvant RT.
Neoadjuvant RT does not appear to increase short-term (30-day) morbidity or mortality following resection of RPS. Continued investigation is needed to better define the role for radiation therapy among patients with this disease.
Retroperitoneal sarcoma; Sarcoma; Radiation therapy; Radiotherapy; Neoadjuvant; Preoperative; Outcomes; Short-term outcomes; 30-day outcomes
The racial/ethnic composition of the United States is shifting rapidly, with non-Hispanic Asian-Americans, Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race individuals the fastest growing segments of the population. We determined new drug use estimates for these rising groups. Prevalences among Whites were included as a comparison.
Data were from the 2005–2011 National Surveys on Drug Use and Health. Substance use among respondents aged ≥12 years was assessed by computer-assisted self-interviewing methods. Respondents’ self-reported race/ethnicity, age, gender, household income, government assistance, county type, residential stability, major depressive episode, history of being arrested, tobacco use, and alcohol use were examined as correlates. We stratified the analysis by race/ethnicity and used logistic regression to estimate odds of drug use.
Prevalence of past-year marijuana use among Whites increased from 10.7% in 2005 to 11.6–11.8% in 2009–2011 (P<0.05). There were no significant yearly changes in drug use prevalences among Asian-Americans, NHs/PIs, and mixed-race people; but use of any drug, especially marijuana, was prevalent among NHs/PIs and mixed-race people (21.2% and 23.3%, respectively, in 2011). Compared with Asian-Americans, NHs/PIs had higher odds of marijuana use, and mixed-race individuals had higher odds of using marijuana, cocaine, hallucinogens, stimulants, sedatives, and tranquilizers. Compared with Whites, mixed-race individuals had greater odds of any drug use, mainly marijuana, and NHs/PIs resembled Whites in odds of any drug use.
Findings reveal alarmingly prevalent drug use among NHs/PIs and mixed-race people. Research on drug use is needed in these rising populations to inform prevention and treatment efforts.
Asian Americans; drug use; marijuana use; mixed race; multiple race; Native Hawaiians; nonmedical opioid use; Pacific Islanders
Little is known about behavioral healthcare needs of Asian Americans (AAs), Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race people (MRs)—the fastest growing segments of the U.S. population. We examined substance use disorder (SUD) prevalences and comorbidities among AAs, NHs/PIs, and MRs (N=4572) in a behavioral health electronic health record database. DSM-IV diagnoses among patients aged 1–90 years who accessed behavioral healthcare from 11 sites were systematically captured: SUD, anxiety, mood, personality, adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic/schizophrenic, sleep, and somatoform diagnoses. Of all patients, 15.0% had a SUD. Mood (60%), anxiety (31.2%), adjustment (30.9%), and disruptive (attention deficit-hyperactivity, conduct, oppositional defiant, disruptive behavior diagnosis, 22.7%) diagnoses were more common than others (psychotic 14.2%, personality 13.3%, other childhood-onset 11.4%, impulse-control 6.6%, cognitive 2.8%, eating 2.2%, somatoform 2.1%). Less than 1% of children aged <12 years had SUD. Cannabis diagnosis was the primary SUD affecting adolescents aged 12–17. MRs aged 35–49 years had the highest prevalence of cocaine diagnosis. Controlling for age at first visit, sex, treatment setting, length of treatment, and number of comorbid diagnoses, NHs/PIs and MRs were about two times more likely than AAs to have ≥2 SUDs. Regardless of race/ethnicity, personality diagnosis was comorbid with SUD. NHs/PIs with a mood diagnosis had elevated odds of having SUD. Findings present the most comprehensive patterns of mental diagnoses available for treatment-seeking AAs, NHs/PIs, and MRs in the real-world medical setting. In-depth research is needed to elucidate intraracial and interracial differences in treatment needs.
Asian Americans; comorbidity; mixed race; Native Hawaiians; Pacific Islanders; substance use disorder
Identifying sources of heterogeneity in late life depression remains an important focus of psychiatric investigation. Community samples are particularly informative since many older adults have clinically significant depressive symptoms but fail to meet criteria for major depression and older adults generally do not seek treatment for their depressive symptoms. The primary data used for these analyses were those collected in a community-based survey of over 3000 adults age 65 or older followed for up to ten years. Depressive symptoms were measured by the Center for Epidemiologic Studies-Depression scale (CES-D). Latent class analysis was used to identify clusters of participants based on their symptom profiles at baseline. Mixed models were used to examine trajectories of CES-D scores based on cluster assignment. A model with three unique clusters best fit the data. Cluster 1 (59%) had a low probability of any symptom endorsement. Cluster 2 (31%) endorsed as a group some negative affect and somatic symptoms but their endorsement of low positive affect did not differ from Cluster 1. Participants in Cluster 3 (10%) had a higher probability of endorsement of all symptoms compared to Clusters 1 and 2. The results did not appreciably differ when symptom severity was included. Cluster assignment was a significant predictor of change in CES-D score over the ten-year follow-up period, and the effects over time differed by sex. Depressive symptom profiles predict the longitudinal course of depression in a community sample of older adults, findings that are important especially in primary care settings.
Non-Hispanic Asian Americans, Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race individuals are the fastest growing segments of the US population. We examined prevalences and correlates of tobacco use among these understudied groups. Prevalences among whites were included as a comparison.
Data were drawn from the 2002–2010 National Surveys on Drug Use and Health. Respondents aged ≥12 years were assessed for current (past-month) use of cigarettes, cigars, smokeless tobacco (chewing tobacco, snuff), and pipe tobacco. Respondents’ race/ethnicity, age, sex, household income, government assistance, urbanicity of residence, residential stability, self-rated health, alcohol use, and drug use were examined as correlates.
Between 2002 and 2010, there was a decline in the prevalence of cigarette smoking among whites (26.9% in 2002; 24.3% in 2010) and Asian Americans (18.0% in 2002; 11.1% in 2010). Prevalence of pipe tobacco use among mixed-race individuals increased from 0.2% in 2002 to 1.6% in 2010; there was little change in the prevalence of cigar and smokeless tobacco use in these racial/ethnic groups. Adjusted analyses showed that, compared with Asian Americans, mixed-race individuals had greater odds of using four tobacco products, and NHs/PIs had greater odds of using cigarettes, cigars, and smokeless tobacco. Regardless of race/ethnicity, male sex was a correlate of use of cigars, smokeless tobacco, and pipe tobacco; alcohol and drug use increased the odds of cigarette and cigar smoking.
These new findings show prevalent tobacco use among NHs/PIs and mixed-race individuals, and highlight the importance of including these populations in future research and reporting.
Asian Americans; mixed race; Pacific Islanders; cigarette smoking; tobacco use; National Survery on Drug Use and Health (NSDUH)
To examine prevalence of tobacco use and identify psychiatric symptoms and substance use correlates of tobacco use comparing adults 50-64 years of age with those 65+ years of age (N=10,891).
Data were from the 2008–2009 U.S. National Surveys on Drug Use and Health.
Past-year tobacco use was one-half as frequent among adults aged 65+ years (14.1%) compared to adults aged 50–64 years (30.2%); the latter group surpassed the former in rates of cigarette smoking (24.8 % vs. 10.6%), daily cigarette smoking (16.5% vs. 7.1%), cigar smoking (7.4% vs. 2.3%), and smokeless tobacco use (2.5% vs. 1.7%). Increased odds of cigarette smoking were noted among men, whites, African Americans, and those who had less education, had lower income, were not currently married, or were binge drinkers or illicit/non-medical drug users. In controlled analyses, odds ratio in those 65+ years of age who had smoked during the past year was 2.2 for binge drinking and 3.5 for illicit or non-medical drug use. Odds ratio of binge drinking among those 65+ years of age for cigar smokers during the past year was 3.1. Past year cigarette smoking was not associated with reports of symptoms of depression or anxiety in the 65+ age group.
Tobacco use is less prevalent among adults 65+ years of age yet continues to be strongly associated with binge drinking and illicit or non-medical drug use. Preventive efforts to decrease these substance use problems should include programs to decrease tobacco use.
Cigarette smoking; cigar smoking; older adults; smokeless tobacco use; epidemiology; binge drinking, substance use, depression, anxiety
It is unclear whether distinct weight-related trajectory classes, differing in course, demographics, and health characteristics, exist in the elderly population.
Data came from the 10-year (1986–1996) Duke Established Populations for Epidemiologic Studies of the Elderly study of 3,861 black (54%) and white (46%) participants aged 65–105 years. Latent-class trajectories of body mass index (BMI: kg/m2) based on self-reported weight and height at baseline, 3, 6, and 10 years later were determined using generalized mixture models. Polytomous logistic regression was used to identify baseline demographic and health characteristics that distinguished the trajectories, and 10-year postbaseline data to confirm the findings.
We identified three trajectories: normal weight (BMI ~24, 27.6% of the sample), overweight (BMI ~26, 65.1%), and obese (BMI ~31, 7.3%). Demographic characteristics distinguished the three trajectories: highest odds of blacks, women, and less education in the obese trajectory, lowest in the normal-weight trajectory. Obese and overweight differed adversely from normal-weight trajectories, but not significantly from each other on cognitive impairment, hypertension, and diabetes. Depressive symptomatology was more prevalent in the obese; they were also younger. There was no association with cancer or heart disease.
Distinct trajectories and course of BMI were present in this older population. Weight loss increased with increase in BMI class. Although demographic characteristics distinguished all trajectory classes, adverse health characteristics distinguished the overweight and obese classes from the normal-weight class, but not from each other. Problems associated with education and health are present at study entry and should be addressed earlier in life.
Body mass index; Trajectory; Elderly.
To examine prevalences of substance use disorders (SUD) and comprehensive patterns of comorbidities among psychiatric patients ages 18–64 years (N=40,099) in an electronic health records (EHR) database.
DSM-IV diagnoses among psychiatric patients in a large university system were systematically captured: SUD, anxiety (AD), mood (MD), personality (PD), adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic (schizophrenic), sexual/gender identity, sleep, and somatoform diagnoses. Comorbidities and treatment types among patients with a SUD were examined.
Among all patients, 24.9% (n=9,984) had a SUD, with blacks (35.2%) and Hispanics (32.9%) showing the highest prevalence. Among patients with a SUD, MD was prevalent across all age groups (50.2–56.6%). Patients aged 18–24 years had elevated odds of comorbid PD, adjustment, childhood-onset, impulse-control, psychotic, and eating diagnoses. Females had more PD, AD, MD, eating, and somatoform diagnoses, while males had more childhood-onset, impulse-control, and psychotic diagnoses. Blacks had greater odds than whites of psychotic and cognitive/dementia diagnoses, while whites exhibited elevated odds of PA, AD, MD, childhood-onset, eating, somatoform, and sleep diagnoses. Women, blacks, and Native American/multiple-race adults had elevated odds of using inpatient treatment; men, blacks, and Hispanics had increased odds of using psychiatric emergency care. Comorbid MD, PD, adjustment, somatoform, psychotic, or cognitive/dementia diagnoses increased inpatient treatment.
Patients with a SUD, especially minority members, use more inpatient or psychiatric emergency care than those without. Findings provide evidence for research on understudied diagnoses and underserved populations in the real-world clinical settings.
anxiety disorders; comorbidity; comparative effectiveness research; electronic health records; mood disorders; personality disorders; substance-related disorders
To estimate one-year prevalence and correlates of alcohol abuse, dependence, and subthreshold dependence (diagnostic orphans) among middle-aged and elderly persons in the United States.
2005–2007 National Surveys on Drug Use and Health.
Sample included 10,015 respondents 50–64 years of age and 6,289 respondents 65+ years of age. Data were analyzed by bivariate and multinomial regression analyses.
Sociodemographic variables, alcohol use and DSM-IV abuse and dependence, major depression, nicotine dependence, illicit drug use, and nonmedical use of prescription drugs.
Fifty-one percent of the sample used alcohol during the past year (56% in the 50-64 age group and 43% in the 65+ age group). Overall, 11% (dependence 1.9%, abuse 2.3%, and subthreshold dependence 7.0%) of adults aged 50–64 and about 6.7% (dependence 0.6%, abuse 0.9%, and subthreshold dependence 5.2%) of those aged 65+ reported alcohol abuse, dependence or dependence symptoms. Among past-year alcohol users, 20% (dependence 3.4%, abuse 4.0%, and subthreshold dependence 12.5%) of adults aged 50–64 and 15.4% (dependence 1.3%, abuse 2.1%, and subthreshold dependence 12.0%) of those aged 65+ endorsed alcohol abuse or dependence symptoms. “Tolerance” (48%) and “time spent using” (37%) were the two symptoms most frequently endorsed by the subthreshold group. Compared with alcohol users without alcohol abuse or dependence symptoms, Blacks or Hispanics, and those who had nicotine dependence or used nonmedical prescription drugs had increased odds of subthreshold dependence. Diagnostic orphans also were more likely to engage in binge drinking than the asymptomatic group.
Diagnostic orphans among middle-aged and elderly community adults show an elevated rate for binge drinking and nonmedical use of prescription drugs that require attention from health care providers.
Substance abuse among older adults is a looming public health concern. The number of Americans aged 50+ years with a substance use disorder is projected to double from 2.8 million in 2002–2006 to 5.7 million in 2020. The authors provide a review of epidemiological findings for this understudied area of research by focusing on illicit drug use disorders and nonmedical use of prescription drugs among adults aged 50+ years.
MEDLINE and PsychInfo were searched using keywords drug use, drug abuse, drug misuse, substance use disorder, and prescription drug abuse. Using the relatedarticles link, additional articles were screened for inclusion. This review included articles published between 1990 and 2010.
Results from multiple sources indicated a much higher rate of illicit drug use and nonmedical use of prescription drugs and drug-related treatment admissions for persons 50 to 64 years of age compared with adults 65+ years of age. Rates of treatment admissions involving primary use of illicit and misuse of prescription drugs have increased, while rates involving primary use of alcohol only have decreased. Alcohol, opioids/heroin, and cocaine were more likely than other substances to be associated with treatment use. Limited research data suggested the effectiveness of treatments, especially for women. Furthermore, older adults appeared to be less likely than younger adults to perceive substance use as problematic or to use treatment services.
There is robust evidence showing that an increased number of older adults will need substance abuse care in the coming decades. Increasing demands on the substance abuse treatment system will require expansion of treatment facilities and development of effective service programs to address emerging needs of the aging drug-using population.
alcohol; epidemiology; health behaviors; drug abuse; illicit drug use; prescription drug abuse
To identify a potential core set of brief screeners for the detection of individuals with a substance use disorder (SUD) in medical settings.
Data were from two multisite studies that evaluated stimulant use outcomes of an abstinence-based contingency management intervention as an addition to usual care (National Drug Abuse Treatment Clinical Trials Network [CTN] trials 006-007). The sample comprised 847 substance-using adults who were recruited from 12 outpatient substance abuse treatment settings across the United States. Alcohol and drug use disorders were assessed by the DSM-IV Checklist. Data were analyzed by factor analysis, item response theory (IRT), sensitivity, and specificity procedures.
Comparatively prevalent symptoms of dependence, especially inability to cut down for all substances, showed high sensitivity for detecting a SUD (low rate of false negative). IRT-defined severe (infrequent) and low discriminative items, especially withdrawal for alcohol, cannabis, and cocaine, had low sensitivity in identifying cases of a SUD. IRT-defined less severe (frequent) and high discriminative items, including inability to cut down or taking larger amounts than intended for all substances and withdrawal for amphetamines and opioids, showed good-to-high values of area under the receiver operating characteristic curve in classifying cases and non-cases of a SUD.
Findings suggest the feasibility of identifying psychometrically reliable substance dependence symptoms to develop a two-item screen for alcohol and drug disorders.
Clinical trials network; Item response theory; Receiver operating characteristic curve; Brief screening; Substance use disorders
Despite the high occurrence of depressive symptoms in older adults, especially women, little is known about the long-term course of late-life depressive symptoms.
To characterize the natural course of depressive symptoms among elderly women followed for nearly 20 years, going from young old to oldest old.
Using a latent class growth-curve analysis, we analyzed women enrolled in an ongoing prospective cohort study (1988–2009).
Clinic sites in Baltimore, MD, Minneapolis, MN, the Monongahela Valley near Pittsburgh, PA, and Portland, OR.
We studied 7240 community-dwelling women age 65 years or older.
Main Outcome Measure
The Geriatric Depression Scale (GDS) short form (range: 0–15) was used to assess depressive symptoms repeatedly over follow-up.
We identified four latent classes over 20 years, comprising an expected 28% of women with minimal depressive symptoms, 54% with persistently low symptoms, 15% with increasing symptoms, and 3% with persistently high symptoms. In an adjusted model for latent class membership, odds ratios (ORs) for belonging in the increasing and persistently high depressive symptom classes, respectively, compared with minimal symptom group were substantially and significantly (P < .05) elevated for baseline smoking (ORs, 4.69 and 7.97), physical inactivity (ORs, 2.11 and 2.78), small social network (ORs, 3.24 and 6.75), physical impairment (ORs, 8.11 and 16.43), myocardial infarction (ORs, 2.09 and 2.41), diabetes (ORs, 2.98 and 3.03), and obesity (ORs, 1.86 and 2.90).
Over 20 years, approximately 20% of older women experienced persistently high or increasing depressive symptoms. In addition, these women had more comorbidities, physical impairment, and negative lifestyle factors at baseline. These associations support the need for intervention and prevention strategies to reduce depressive symptoms into oldest-old years.
Treatment of peritoneal metastases from appendiceal and colon cancer with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) shows great promise. Although long term disease free survival is achieved for some cases with this procedure, many patients recur. Oncologists have treated such recurrences of appendiceal cancer similarly to colorectal carcinoma, which has been largely ineffective. This study utilizes gene expression analysis of peritoneal metastases to better understand these neoplasms.
From a prospectively maintained database and tissue bank, 41 snap frozen samples of peritoneal metastases (26 appendiceal, 15 colorectal) from patients undergoing HIPEC with complete cytoreduction and >3 years of follow up underwent global gene expression analysis. Distinct phenotypes were identified using unsupervised hierarchical clustering based upon differential gene expression. Survival curves restratified by genotype were generated.
Three distinct phenotypes were found, two consisting of predominantly low grade appendiceal samples (10/13 in Cluster 1 and 15/20 in Cluster 2) and one consisting of predominantly colorectal samples (7/8 in Cluster 3). Cluster 1 consisted of patients with good prognosis and Clusters 2 and 3 consisted of patients with poor prognosis (p=0.006). Signatures predicted survival of low (Cluster 1) vs. high risk (Cluster 2) appendiceal (p=.04) and low risk appendiceal (Cluster 1) vs. colon primary (Cluster 3) (p=.0002).
This study represents the first use of gene expression profiling for appendiceal cancer, and demonstrates genomic signatures quite distinct from colorectal cancer, confirming their unique biology. Consequently, therapy for appendiceal lesions extrapolated from colonic cancer regimens may be unfounded. These phenotypes may predict outcomes guiding patient management. HIPEC, hyperthermic intraperitoneal chemotherapy PC, peritonel carcinomatosis OTC, optimal cutting temperature GSEA, gene set enrichment analysis
To estimate the frequency, distribution, and correlates of non-prescription use of pain relievers among middle aged and elderly persons in the United States.
Cross-sectional data analysis of a national community survey.
The 2005 and 2006 National Surveys on Drug Use and Health (NSDUH).
10,953 respondents 50 years of age and older (6,717 respondents 50-64 years of age and 4,236 respondents 65+ years of age).
Social and demographic variables, detailed assessment of non-prescription use (and abuse) of prescription pain relievers (e.g., acetaminophen with codeine, morphine), substance use, major depression, self-reported medical illnesses, and self-rated health.
Non-prescription use of prescription pain relievers was reported by 1.4% of the sample during the past year. Combinations of acetaminophen with hydrocodone or propoxyphene were the most commonly used drugs. Use was associated with younger age (Odds Ratio, OR = 2.39, 95% CI = 1.31–4.36), American Indian/Alaska native (OR = 8.78, 95% CI = 2.50–30.85) and use of marijuana (OR = 7.07, 95% CI = 3.99–12.53). Less than 10% of non-prescription users were abusing these medications or dependent upon them.
In a representative sample of middle aged and older adults, non-prescription use of prescription pain relievers is relatively uncommon. Nevertheless, the much higher use among middle aged adults suggests that as this cohort ages, the problem may increase among the elderly.
elderly; pain relievers; non-prescription use; epidemiology; opioids; prescription drug misuse
Initial research on older smokers suggests that a subgroup of smokers with higher levels of psychological distress and health problems may be more likely to quit smoking than older smokers with fewer such problems. The present study, based on prospective data from a biracial sample of older adults (N = 4,162), examined characteristics of older adult smokers by race and gender.
The present study uses both cross-sectional and prospective data to examine the association between smoking behavior, smoking cessation, health functioning, and psychological distress in a biracial sample of community-dwelling older adults.
We found baseline psychological distress to be associated with poor health functioning. Consistent with hypotheses, baseline (Time 1) psychological distress predicted smoking cessation 3 years later (Time 2). Moreover, the change in health problems between Time 1 and Time 2 fully mediated the association between Time 1 distress and smoking cessation.
Smoking cessation behavior of older adults is best explained by higher levels of distress and health problems regardless of race or gender. These findings may have important treatment implications regarding smoking cessation programs among older adults. Older adult smokers with higher levels of psychological distress and health problems may be more motivated to quit smoking than those with fewer such problems. These difficulties should be targeted within the context of the smoking cessation protocol. Also, we identified a subgroup of older smokers who are reporting fairly good health and lower levels of distress and who are less likely to quit smoking. Motivational methods may need to be developed to engage this group in smoking cessation treatment.
Improving identification and treatment for substance use disorders (SUDs) is a national priority, but data about various drug use disorders encountered in emergency departments (EDs) are lacking. We examined past-year substance use and SUDs (alcohol, 9 drug classes) among adult ED users. Prevalences of substance use and SUDs among ED non-users were calculated for reference purposes.
Using data from the 2007–2009 National Surveys on Drug Use and Health, we assessed SUDs among noninstitutionalized adults aged ≥18 years who responded to standardized survey questions administered by audio computer-assisted self-interviewing methods.
Of all adults (N=113,672), 27.8% used the ED in the past year. ED users had higher prevalences than ED non-users of coexisting alcohol–drug use (15.2% vs. 12.1%), drug use (any drug, 16.9% vs. 13.0%; marijuana, 12.1% vs. 9.7%; opioids, 6.6% vs. 4.1%), and alcohol or drug disorders (11.0% vs. 8.5%). Among substance users, the ED group on average spent more days using drugs than the non-ED group; ED users manifested higher conditional rates of SUDs than ED non-users (alcohol or drugs, 15.9% vs. 11.7%; marijuana, 16.6% vs. 13.2%; cocaine, 33.2% vs. 22.3%; opioids, 20.6% vs. 10.0%; stimulants, 18.6% vs. 9.2%; sedatives, 35.0% vs. 4.4%; tranquilizers, 12.4% vs. 5.2%). Regardless of ED use status, substance-using young adults, men, and less-educated adults showed elevated odds of having a SUD.
Drug use is prevalent and combined with high rates of drug use disorders among drug users seen in the ED.
alcohol use disorders; drug abuse; drug use disorders; prescription drug abuse; substance use disorder
To compare symptom expression in primarily middle-aged (<60) and older (60+) depressed patients and determine if symptom profiles differed by age.
Patients diagnosed with major depression (n=664) were screened using the Center for Epidemiologic Studies – Depression Scale and sections of the Diagnostic Interview Schedule. Patients were separated into homogeneous clusters based on symptom endorsement using latent class analysis.
Older patients were less likely to endorse crying spells, sadness, feeling fearful, being bothered, or feeling life a failure, but were more likely to endorse poor appetite and loss of interest in sex. Older patients were also less likely to report enjoying life, feeling as good as others, feeling worthless, wanting to die and thinking about suicide. In two latent class models with depressive symptoms as indicators, three-class models best fit the data. Profiles supported heterogeneity in symptom expression. Clusters differed by age when other demographic, clinical, health and social variables were controlled, but did not support age-specific symptom profiles. Overall, older patients had later age of onset, had fewer lifetime spells, were more likely to have ever received ECT and were less likely to have comorbid anxiety. Older patients also had more cognitive impairment, health conditions, and mobility limitations, but had higher levels of subjective social support and had experienced fewer stressful life events.
There are age differences in symptom endorsement between younger/middle-aged and older patients with major depression. The data, however, did not identify a symptom profile unique to late-life depression.
depression; symptoms; age differences; latent class analysis
While item response theory (IRT) research shows a latent severity trait underlying response patterns of substance abuse and dependence symptoms, little is known about IRT-based severity estimates in relation to clinically relevant measures. In response to increased prevalences of marijuana-related treatment admissions, an elevated level of marijuana potency, and the debate on medical marijuana use, we applied dimensional approaches to understand IRT-based severity estimates for marijuana use disorders (MUDs) and their correlates while simultaneously considering gender- and race/ethnicity-related differential item functioning (DIF). Using adult data from the 2008 National Survey on Drug Use and Health (N=37,897), DSM-IV criteria for MUDs among past-year marijuana users were examined by IRT, logistic regression, and multiple indicators–multiple causes (MIMIC) approaches. Among 6,917 marijuana users, 15% met criteria for a MUD; another 24% exhibited subthreshold dependence. Abuse criteria were highly correlated with dependence criteria (correlation=0.90), indicating unidimensionality; item information curves revealed redundancy in multiple criteria. MIMIC analyses showed that MUD criteria were positively associated with weekly marijuana use, early marijuana use, other substance use disorders, substance abuse treatment, and serious psychological distress. African Americans and Hispanics showed higher levels of MUDs than whites, even after adjusting for race/ethnicity-related DIF. The redundancy in multiple criteria suggests an opportunity to improve efficiency in measuring symptom-level manifestations by removing low-informative criteria. Elevated rates of MUDs among African Americans and Hispanics require research to elucidate risk factors and improve assessments of MUDs for different racial/ethnic groups.
Differential item functioning; item response theory; multiple indicators–multiple causes model; marijuana use disorders
To identify trajectories of depressive symptoms in older community residents.
Depressive symptomatology, based on a modified Center for Epidemiological Studies–Depression scale, was obtained at years 0, 3, 6, and 10, in the Duke Established Populations for Epidemiologic Studies of the Elderly (N=4,162). Generalized growth mixture models identified the latent class trajectories present. Baseline demographic, health and social characteristics distinguishing the classes were identified using multinomial logistic regression.
Four latent class trajectories were identified. Class 1-- stable low depressive symptomatology (76.6% of the sample); class 2 – initially low depressive symptomatology, increasing to the subsyndromal level (10.0%); class3 -- stable high depressive symptomatology (5.4%); class 4 –high depressive symptomatology improving over 6 years before reverting somewhat (8.0%). Class 1 was younger, male, with better education, health, and social resources, in contrast to class 3. Class 2 had poorer cognitive functioning and higher death rate. Class 4 had better health and social resources.
Reduction in high depressive symptomatology is associated with more education, better health, fewer stressful events, and a larger social network. Increasing depressive symptomatology is accompanied by poorer physical and cognitive health, more stressful life events, and greater risk of death.
depressive symptomatology; trajectories; community sample; longitudinal; elderly
To address an urgent need for screening of substance use problems in medical settings, we examined substance-specific dependence criteria as potential brief screeners for the detection of patients with a substance use disorder (SUD).
The sample included 920 opioid-dependent adults who were recruited from outpatient treatment settings at 11 programs in 10 U.S. cities and who completed intake assessments of SUDs for a multisite study of the National Drug Abuse Treatment Clinical Trials Network (CTN003). Data were analyzed by factor analysis, item response theory (IRT), sensitivity, and specificity procedures.
Across all substances (alcohol, amphetamines, cannabis, cocaine, sedatives), withdrawal was among the least prevalent symptoms, while taking large amounts and inability to cut down were among the most prevalent symptoms. Items closely related to the latent trait of a SUD showed good-to-high values of area under the receiver operating characteristic curve in identifying cases of a SUD; IRT-defined severe and less discriminative items exhibited low sensitivity in identifying cases of a SUD (withdrawal for all substances; time using for alcohol and sedatives; giving up activities for sedatives).
Study results suggest that withdrawal and time using are much less reliable indicators for a SUD than taking larger amounts than intended and inability to cut down and should be studied further for consideration in developing a simplified tool for screening patients for SUDs in medical settings. These findings have implications for the use of common health indicators in electronic health records systems to improve patient care.
clinical trials network; item response theory; receiver operating characteristic curve; brief screening; sensitivity; specificity; substance use disorders
This study examined national trends, patterns, correlates, and barriers to substance abuse treatment use by adolescents aged 12–17 years who met at least one of the past-year criteria for prescription opioid abuse or dependence (N=1788).
Data were from the 2005–2008 National Surveys of Drug Use and Health (NSDUH). Past-year substance use disorders, major depression, and treatment use were assessed by audio computer-assisted self-interviewing.
About 17% of adolescents with opioid dependence (n=434) and 16% of those with opioid abuse (n=355) used any substance abuse treatment in the past year compared with 9% of subthreshold users, i.e., adolescents who reported 1–2 prescription opioid dependence criteria but no abuse criteria (n=999). Only 4.2% of adolescents with opioid dependence, 0.5% of those with abuse, and 0.6% of subthreshold users reported a perceived need for treatment of nonmedical opioid use. Self-help groups and outpatient rehabilitation were the most commonly used sources of treatment. Few black adolescents used treatment (medical settings, 3.3%; self-help groups, 1.7%) or reported a need for treatment (1.8%). Talking to parents/guardians about dangers of substance use increased the odds of treatment use. Barriers to treatment use included —wasn’t ready to stop substance use,” —didn't want others to find out,” and —could handle the problem without treatment.”
Adolescents with prescription opioid use disorders markedly underutilize treatment. Non-financial barriers are pervasive, including stigma and a lack of perceived treatment need.
Opioid use disorders; Misuse of prescription opioids; Self-help groups; Substance abuse treatment
This study applied item response theory (IRT) and latent class analysis (LCA) procedures to examine the dimensionality and heterogeneity of comorbid substance use disorders (SUDs) and explored their utility for standard clinical assessments, including the Addiction Severity Index (ASI), HIV Risk Behavior Scale (HRBS), and SF-36 quality-of-life measures.
The sample included 343 opioid-dependent patients enrolled in two national multisite studies of the U.S. National Drug Abuse Treatment Clinical Trials Network (CTN001–002). Patients were recruited from inpatient and outpatient addiction treatment settings at 12 programs. Data were analyzed by factor analysis, IRT, LCA, and latent regression procedures.
A two-class LCA model fit dichotomous SUD data empirically better than one-parameter and two-parameter IRT models. LCA distinguished 10% of severe comorbid opioid-dependent individuals who had high rates of all SUDs examined—especially amphetamine and sedative abuse/dependence—from the remaining 90% who had SUDs other than amphetamine and sedative abuse/dependence (entropy=0.99). Item-level results from both one-parameter and two-parameter IRT models also found that amphetamine and sedative abuse/dependence tapped the more severe end of the latent poly-SUD trait. Regardless of whether SUDs were defined as a continuous trait or categorically, individuals characterized by a high level of poly-SUD demonstrated more psychiatric problems and HIV risk behaviors.
A combined application of categorical and dimensional latent approaches may improve the understanding of comorbid SUDs and their associations with other clinical indicators. Abuse of sedatives and methamphetamine may serve as a useful marker for identifying subsets of opioid-dependent individuals with needs for more intensive interventions.
clinical trials network; comorbidity; item response theory; latent class analysis; multiple indicators–multiple causes model; opioid dependence; polysubstance use; substance use disorders