This study characterizes adults who report being physically abused during childhood, and examines associations of reported type and frequency of abuse with adult mental health. Data were derived from the 2000–2001 and 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions, a large cross-sectional survey of a representative sample (N = 43,093) of the U.S. population. Weighted means, frequencies, and odds ratios of sociodemographic correlates and prevalence of psychiatric disorders were computed. Logistic regression models were used to examine the strength of associations between child physical abuse and adult psychiatric disorders adjusted for sociodemographic characteristics, other childhood adversities, and comorbid psychiatric disorders. Child physical abuse was reported by 8% of the sample and was frequently accompanied by other childhood adversities. Child physical abuse was associated with significantly increased adjusted odds ratios (AORs) of a broad range of DSM-IV psychiatric disorders (AOR = 1.16–2.28), especially attention-deficit hyperactivity disorder, posttraumatic stress disorder, and bipolar disorder. A dose-response relationship was observed between frequency of abuse and several adult psychiatric disorder groups; higher frequencies of assault were significantly associated with increasing adjusted odds. The long-lasting deleterious effects of child physical abuse underscore the urgency of developing public health policies aimed at early recognition and prevention.
Exposure to stress often is psychologically distressing. The impact of stress on alcohol use and the risk of alcohol use disorders (AUDs) depends on the type, timing during the life course, duration, and severity of the stress experienced. Four important categories of stressors that can inQuence alcohol consumption are general life stress, catastrophic/fateful stress, childhood maltreatment, and minority stress. General life stressors, including divorce and job loss, increase the risk for AUDs. Exposure to terrorism or other disasters causes population-level increases in overall alcohol consumption but little increase in the incidence of AUDs. However, individuals with a history of AUDs are more likely to drink to cope with the traumatic event. Early onset of drinking in adolescence, as well as adult AUDs, are more common among people who experience childhood maltreatment. Finally, both perceptions and objective indicators of discrimination are associated with alcohol use and AUDs among racial/ethnic and sexual minorities. These observations demonstrate that exposure to stress in many forms is related to subsequent alcohol consumption and AUDs. However, many areas of this research remain to be studied, including greater attention to the role of various stressors in the course of AUDs and potential risk moderators when individuals are exposed to stressors.
Alcohol use and abuse; alcohol use disorders; stress; stress as a cause of alcohol and other drug use; risk factors; psychological stress; stress response; coping; stressors; general life stress; catastrophe; child abuse; minority group; epidemiological indicators
Ecstasy use is prevalent among young people and often co-occurs with other drug use, but little is known about the past 12-month and lifetime psychiatric comorbidity and specific additional drug abuse among young adult ecstasy users in the general population. To provide this information, we compared current ecstasy users to former users, other illicit drug users, and non-illicit drug users.
Data were gathered in a face-to-face survey of the United States conducted in the 2001–2002 (NESARC). Participants were household and group quarters residents aged 18–29 years (n = 8666). We measured current ecstasy use defined as any use in the past year; former ecstasy use as use prior to the past year only; other lifetime drug use included any drug other than ecstasy; lifetime non-illicit drug use as no illicit drug use. Associations were determined for nine other classes of illicit drugs, eight personality disorders, and seven mood and anxiety disorders.
Of current ecstasy users, 44% used >3 other classes of illicit drugs in the past year, compared to 1.6% of non-ecstasy drug users. Current ecstasy use was associated with current anxiety (OR = 3.7), specifically panic disorder (OR = 7.7) and specific phobia (OR = 4.1), also alcohol abuse (OR = 21.6) and dependence (OR = 4.1) and any personality disorder (OR = 5.1) compared to non-illicit drug users.
Results indicate important differences in comorbidities of current and former ecstasy users compared to other drug users and lifetime non-illicit drug users that may affect phenotype definitions and etiologic studies. Ecstasy use may represent a distinct population of drug users for which unique treatments may be necessary.
Ecstasy; MDMA; Epidemiology; Young adult; Poly-drug
The authors examined treatment utilization and outcomes over 2 years among patients admitted to emergency departments with early-phase primary or substance-induced psychosis. The main hypothesis was that patients with substance-induced psychosis would have a more benign course of illness than those with primary psychosis.
Using a prospective naturalistic cohort study design, the authors compared 217 patients with early-phase primary psychosis plus substance use and 134 patients with early-phase substance-induced psychosis who presented to psychiatric emergency departments at hospitals in Upper Manhattan. Assessments at baseline and at 6, 12, 18, and 24 months included psychiatric diagnoses, service use, and institutional outcomes using the Psychiatric Research Interview for Substance and Mental Disorders; psychiatric symptoms using the Positive and Negative Syndrome Scale; social, vocational, and family functioning using the World Health Organization Psychiatric Disability Assessment Schedule; and life satisfaction using the Quality of Life Interview. Longitudinal analyses were conducted using generalized estimating equations.
Participants with primary psychosis were more likely to receive antipsychotic and mood-stabilizing medications, undergo hospitalizations, and have out-patient psychiatric visits; those with substance-induced psychosis were more likely to receive addiction treatments. Only a minority of each group received minimally adequate treatments. Both groups improved significantly over time on substance dependence, psychotic symptoms, homelessness, and psychosocial outcomes, and few group-by-time interactions emerged.
Patients presenting to Upper Manhattan emergency departments with either early-phase primary psychosis or substance-induced psychosis improved steadily over 2 years despite minimal use of mental health and substance abuse services.
Questions relevant to DSM-V alcohol use disorders (AUD) include whether dimensional measures provide more information than categorical diagnoses, whether to combine abuse and dependence criteria, and whether to add a new diagnostic criterion, binge drinking. Binary and dimensional models of three versions of AUD criteria were investigated: (1) dependence criteria; (2) abuse and dependence criteria combined; and (3) abuse and dependence criteria combined with a binge drinking criterion added. In a national sample of lifetime drinkers (N = 27,324), these models of AUD criteria were investigated in relation to two well-established risk factors for AUD, family history and early drinking onset. Logistic or Poisson regression modeled the relationships between the validating variables and dependence in categorical, dimensional and hybrid forms; Wald tests were used to assess differences between the dimensional, categorical and hybrid models. Alcohol dependence criteria represented a single continuum (family history Wald = 9.93, p = 0.13; early drinking Wald = 7.62, p = 0.27) with no support for a categorical or hybrid version of alcohol dependence. Adding four abuse criteria produced similar results for family history (Wald = 15.4, p = 0.12) although with early drinking, this model showed a trend towards deviating from the data (Wald = 16.7, p = 0.08). No support was found for any diagnostic threshold at 3, 4, 5, 6, or 7 criteria when abuse and dependence were combined. Adding binge drinking resulted in a significant departure from linearity for family history (Wald = 21.8, p = 0.03) and early drinking (Wald = 23.9, p = 0.01). The number of alcohol dependence and abuse criteria met should be explored further as a useful AUD severity indicator or phenotype.
Alcohol use disorders; DSM-IV diagnoses; Dimensional and categorical diagnoses; NESARC
Research suggests parental divorce during childhood increases risk of suicide attempt for male but not female offspring. The negative impact on offspring associated with parental divorce may be better explained by parental psychopathology, such as depression. We examined whether adult offspring of parental divorce experience elevated risk of suicide attempt, controlling for parental history of depression, and whether the risk varies by the gender of the offspring. Using the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the sample consists of respondents who experienced parental divorce (N = 4895). Multivariable regressions controlled for age, race/ethnicity, income, marital status, and parental history of depression. Females living with their fathers were significantly more likely to report lifetime suicide attempts than females living with their mothers, even after controlling for parental depression. Findings suggest that childhood/adolescent parental divorce may have a stronger impact on suicide attempt risk in female offspring than previously recognized.
Parental divorce; gender; offspring; suicide attempt; depression
Purpose of review
The comorbidity between psychiatric and substance use disorders remains an important phenomenon to understand, and an active area of investigation. The purpose of this review is to highlight key 2011 issues and novel findings on psychiatric and substance disorders comorbidity from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large national survey of the US general population.
Topics of active investigation included the internalizing/externalizing meta-structure of common mental disorders; the 10 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) personality disorders; the 3-year incidence and persistence of disorders; treatment of major depression; and many other topics not as easily categorized.
Meta-structure may increasingly offer a parsimonious way of addressing comorbidity, although adding new disorders adds complexity and the value of etiologic analyses utilizing broad dimensions of psychopathology rather than individual disorders is not yet fully known. Expanding the range of personality disorders beyond antisocial personality disorder appears essential in understanding the incidence and persistence of substance use disorders. Substance use disorders have low rates of treatment relative to major depression, but increase the likelihood of depression treatment among comorbid cases, a phenomenon that needs to be understood. These comorbidity studies provide much novel information, and indicate many potentially fruitful directions for new research.
alcohol; comorbidity; drug; epidemiology; psychiatric; substance
The course of alcohol disorders in women is often described as “telescoped” compared to that in men, with a later age at initiation of alcohol use but shorter times from use to dependence and treatment. This study examined evidence for such a telescoping effect in the general population and tested birth cohort effects for gender differences.
Data from two U.S. national surveys conducted 10 years apart (1991–1992 and 2001–2002) using the same diagnostic instrument (the Alcohol Use Disorder and Associated Disabilities Interview Schedule–IV) were used to analyze five birth cohorts. Age at initiation of alcohol use, time from first use to dependence, and time from dependence to first treatment were analyzed. Interaction terms (cohort by gender; cohort by gender by time) were tested in Cox proportional hazards models.
Little evidence was found for a telescoping effect in women. For alcohol use and dependence, cohort and gender interacted, which suggests that gender differences are diminished in more recent cohorts. A three-way interaction of cohort, gender, and time was significant for time from first use to dependence, suggesting that men have a shorter time to dependence, especially in younger cohorts.
A telescoping effect is not evident in the general population. Gender differences in the overall hazard of alcohol use and dependence are decreasing in more recent cohorts, while gender differences in time from first use to dependence are increasing. These findings challenge the commonly held notion of a gender-specific course of alcohol disorders and suggest the need for a greater clinical focus on problem drinking in women and further research on accelerated time to dependence in men.
Despite the increased prevalence of weight discrimination, few studies have examined the association between perceived weight discrimination and the prevalence of current psychiatric disorders in the general population. This study utilized a subsample of overweight and obese individuals (N = 22,231) from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a cross-sectional nationally representative study of noninstitutionalized US adults. Perceived weight discrimination is associated with substantial psychiatric morbidity and comorbidity. These results remained significant after adjusting for a potential confound, perceived stress. Moreover, social support did not buffer against the adverse effects of perceived weight discrimination on mental health. Controlling for BMI did not diminish the associations, indicating that perceived weight discrimination is potentially harmful to mental health regardless of weight. These results highlight the urgent need for a multifaceted approach to address this important public health issue, including interventions to assist overweight individuals in coping with the mental health sequelae of perceived weight discrimination.
The goal of this study was to determine the association between mental disorders and cigarette consumption and nicotine dependence.
Data were drawn from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a nationally representative survey of adults (N=43,093) aged 18 and older. Relationships between specific anxiety disorders, mood disorders, non-dependent cigarette use, nicotine dependence among the whole sample, and nicotine dependence among cigarette users were examined.
After adjusting for demographics and comorbid mental disorders, generalized anxiety disorder (OR = 1.16 (1.29–1.51)), specific phobia (OR =1.35 (1.21–1.51)), panic disorder (PD) (OR = 1.90 (1.62–2.23)), major depression (MDD) (OR = 1.31 (1.16–1.48)), and bipolar disorder (OR = 1.30 (1.09–1.54)) were associated with increased likelihood of non-dependent cigarette use. Specific phobia (OR = 1.69 (1.49–1.91)), PD (OR = 1.82 (1.50–2.21)), MDD (OR = 1.59 (1.38–1.84)), and bipolar disorder (OR = 1.71 (1.39–2.09)) were associated with increased odds of nicotine dependence among the whole sample; social phobia (OR = 1.69 (1.19–2.40)), specific phobia (OR =1.69 (1.43–2.01)), MDD (OR =1.65 (1.34–2.02)), and bipolar disorder (OR = 2.38 (1.74–3.24)) were associated with increased risk of nicotine dependence among cigarette users.
Specific anxiety disorders and mood disorders were uniquely associated with non-dependent cigarette use, nicotine dependence among the whole sample, and the risk of nicotine dependence among cigarette users in the United States. Findings suggest that demographic differences, comorbid mood, anxiety, substance, and personality disorders all contributed to previously observed associations between mental disorders and nicotine dependence, explaining these links in some but not all cases.
To examine aspects of Latino experience in the US as predicting service utilization for mood, anxiety, and substance disorders.
Latino participants 18 and older in the NESARC (N = 6,359), a US national face to face survey. Outcomes were lifetime service utilization for DSM-IV lifetime mood/anxiety or substance disorders, diagnosed via structured interview (AUDADIS-IV). Main predictors were ethnic subgroup, ethnic identity, linguistic/social preferences, nativity/years in the US, and age at immigration.
Higher levels of Latino ethnic identity and Spanish language/Latino social preferences predicted lower service utilization for mood disorders [ethnic identity OR = 0.52, language/social OR = 0.44] and anxiety disorders [ethnic identity OR = 0.67, language/social OR = 0.47], controlling for ethnic subgroup, disorder severity, time spent in the US, and economic and practical barriers Service utilization for alcohol/drug disorders was low across all Latino subgroups, without variation by examined predictors.
Ethnic/cultural factors are strong determinants of service utilization for mood/anxiety, but not substance use disorders among Latinos in the US strategies to increase service utilization among Latinos with psychiatric disorders should be disorder specific, and recognize the role of ethnicity and identity as important components of a help-seeking model.
Hispanic; Service use; Mental health; Ethnic identity
Prescriptions for anxiety medications have increased substantially in recent years. Individuals with anxiety disorders are at risk of nonmedical use of these medications, but information about whether this risk is elevated among patients with a prescription for such medications is lacking. The authors compared risk of nonmedical use in individuals in a national sample with and without a prescription for anxiety medication and identified characteristics associated with nonmedical use.
Data were drawn from face-to-face surveys of 34,653 adult participants in the National Epidemiologic Survey on Alcohol and Related Conditions. The risk of nonmedical use of prescription anxiety medication and associated drug use disorders was computed for individuals who had or had not ever received a prescription for anxiety medication; among those who had received a prescription, characteristics associated with nonmedical use were analyzed.
Prescription of anxiety medication was associated with lifetime and past-year nonmedical use (odds ratios, 1.6 and 1.9, respectively) and lifetime DSM-IV abuse or dependence (odds ratio, 2.6). Among respondents who received a prescription (N=4,294), nonmedical use was associated with male sex, younger age, white race, history of use of illicit drugs, history of other drug use disorders, and history of illegal behaviors.
These results indicate that prescription for anxiety medications is associated with nonmedical use of these medications, although the direction of causality cannot be determined in this study. Although anxiety medications have clinical utility, greater clinical attention should be given to the potential for their abuse among patients at particular risk.
Exposure to stress is potentially important in the pathway to alcohol use and alcohol use disorders. Stressors occur at multiple time points across the life course, with varying degrees of chronicity and severity.
We review evidence from epidemiologic studies on the relationship between four different stressors (fateful/catastrophic events, child maltreatment, common adult stressful life events in interpersonal, occupational, financial, and legal domains, and minority stress) and alcohol consumption and alcohol use disorders.
Studies generally demonstrate an increase in alcohol consumption in response to exposure to terrorism or other disasters. Research has demonstrated little increase in incident alcohol use disorders, but individuals with a history of alcohol use disorders are more likely to report drinking to cope with the traumatic event. Childhood maltreatment is a consistent risk factor for early onset of drinking in adolescence and adult alcohol use disorders, and accumulating evidence suggests that specific polymorphisms may interact with child maltreatment to increase risk for alcohol consumption and disorder. Stressful life events such as divorce and job loss increase the risk of alcohol disorders, but epidemiologic consensus on the specificity of these associations across gender has not been reached. Finally, both perceptions of discrimination and objective indicators of discrimination are associated with alcohol use and alcohol use disorders among racial/ethnic and sexual minorities.
Taken together, these literatures demonstrate that exposure to stress is an important component in individual differences in risk for alcohol consumption and alcohol use disorders. However, many areas of this research remain to be studied, including greater attention to the role of various stressors in the course of alcohol use disorders and potential risk moderators when individuals are exposed to stressors.
There is a growing concern that results of tightly controlled clinical trials of individuals with alcohol use disorders may not generalize to broader community samples. To assess the proportion of community-dwelling adults with alcohol dependence who would have been eligible for a typical alcohol dependence treatment study, we developed a new, simple method: we applied a standard set of eligibility criteria commonly used in alcohol outcome studies to a large (n = 43,093) representative US adult sample interviewed face-to-face, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). We found that approximately one-half (50.5%) of all individuals with a DSM-IV diagnosis of alcohol dependence (n = 1484) and 79.4% of those who sought treatment (n = 185) were excluded by one or more study criteria. Individual study criteria excluded from 0.9% to 48.2% of the overall sample and 0.8% to 43.7% of the treatment-seeking sample. For the overall sample, the lack of motivation/compliance and financial situation criteria excluded the largest percentage of individuals. In the treatment-seeking subsample, comorbid medical conditions and legal problems excluded the largest proportions of individuals. Our study provides a new method to assess the generalizability of clinical trials, and gives further evidence that typical clinical trials for alcohol dependence likely exclude most adults with the disorder in the community and under care, and support the notion that clinical trials recruit “pure” rather than “typical” patients. Clinical trials should carefully evaluate the effects of the selected eligibility criteria on the generalizability of their results.
Generalizability; Alcohol dependence; Clinical trials; Eligibility criteria; Inclusion criteria; Exclusion criteria
In previous studies by our group, we found that female offspring of parental divorce and parental remarriage are more susceptible to suicide attempt than male offspring. In this study, we examine whether these findings remain even after controlling for offspring depression. The sample consists of respondents from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions. Multivariable regressions controlled for offspring depression, parental depression, age, race/ethnicity, income, and marital status. Our previous findings that female offspring of parental divorce and parental remarriage are more likely to report a lifetime suicide attempt than male offspring remained even after controlling for offspring depression. Findings suggest that focusing on engaging female offspring who demonstrate symptoms of depression is not sufficient to reduce suicide attempt risk in this group as many at risk individuals will remain unrecognized.
Parental divorce; adult offspring; suicide attempt; offspring depression; parental remarriage
A number of changes have been proposed and investigated in the criteria for substance use disorders in DSM-5. However, although clinical utility of DSM-5 is a high priority, relatively little of the empirical evidence supporting the changes was obtained from samples of substance abuse patients.
Proposed changes were examined in 663 patients in treatment for substance use disorders, evaluated by experienced clinicians using the Psychiatric Research Interview for Substance and Mental Disorders (PRISM). Factor and item response theory analysis was used to investigate the dimensionality and psychometric properties of alcohol, cannabis, cocaine and heroin abuse and dependence criteria, and craving.
The seven dependence criteria, three of the abuse criteria (hazardous use; social/interpersonal problems related to use; neglect of roles to use), and craving form a unidimensional latent trait for alcohol, cannabis, cocaine and heroin. Craving did not add significantly to the total information offered by the dependence criteria, but adding the three abuse criteria and craving together did significantly increase total information for the criteria sets associated with alcohol, cannabis and heroin.
Among adult patients in treatment for substance disorders, the alcohol, cannabis, cocaine and heroin criteria for dependence, abuse (with the exception of legal problems), and craving measure a single underlying dimension. Results support the proposal to combine abuse and dependence into a single diagnosis in the DSM-5, omitting legal problems. Mixed support was provided for the addition of craving as a new criterion, warranting future studies of this important construct in substance use disorders.
Item response theory; Substance abuse; Substance dependence; Craving; DSM-IV; DSM-5
An extensive clinical literature has noted gender differences in the etiology and clinical characteristics of individuals with alcohol dependence (AD). Despite this knowledge, many important questions remain.
Using the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, n=43,093), we examined differences in sociodemographic characteristics, psychiatric and medical comorbidities, clinical correlates, risk factors and treatment-utilization patterns of men (N=2,974) and women (N=1,807) with lifetime AD.
Men with lifetime AD were more likely than women to be diagnosed with any substance use disorder and antisocial personality disorder, whereas women were more likelyto have mood and anxiety disorders. After adjusting for sociodemographic characteristics and gender differences in psychiatric comorbidity in the general population, AD was associated with externalizing disorders and any mood disorder among women only. Men with AD met more criteria, had longer episodes, and were younger at the age of first drink. There were no gender differences in remission rates. Women with AD were more likely to have a family and a spouse with history of alcohol use disorders. Treatment rates were low for both genders, and women were more likely to report social stigmatization as a treatment barrier.
There are important gender differences in the psychiatric comorbidities, risk factors, clinical characteristics, and treatment-utilization patterns among individuals with lifetime AD.
NESARC; Alcohol Dependence; Gender Differences; Epidemiology
To compare the clinical features and course of major depressive episodes (MDE) occurring in subjects with bipolar I disorder (BD-I), bipolar II disorder (BD-II), and major depressive disorder (MDD).
Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (2001–2002), a nationally representative face-to-face survey of more than 43,000 adults in the United States, including 5,695 subjects with lifetime MDD, 935 with BD-I and lifetime MDE, and 494 with BD-II and lifetime MDE. Differences on sociodemographic characteristics and clinical features, course, and treatment patterns of MDE were analyzed.
Most depressive symptoms, family psychiatric history, anxiety disorders, alcohol and drug use disorders, and personality disorders were more frequent—and number of depressive symptoms per MDE were higher—among subjects with BD-I, followed by BD-II, and MDD. BD-I individuals experienced a higher number of lifetime MDE, had the worst quality of life, and received significantly more treatment for MDE than BD-II and MDD subjects. Individuals with BD-I and BD-II experienced their first mood episode about 10 years earlier than those with MDD (21.2, 20.5, and 30.4 years, respectively).
Our results support the existence of a spectrum of severity of MDE, with highest severity for BD-I, followed by BD-II and MDD, suggesting the utility of dimensional assessments in current categorical classifications.
bipolar disorder; clinical classifications; depression; epidemiology
Across the addictions field, the primary outcome in treatment research has been reduction in drug consumption. A comprehensive view of the impact of substance use disorders on human functioning suggests that effective treatments should address the many consequences and features of addiction beyond drug use, a recommendation forwarded by multiple expert panels and review articles. Despite recurring proposals, and a compelling general rationale for moving beyond drug use as the sole standard for evaluating addiction treatment, the field has yet to adopt any core set of “other” measures that are routinely incorporated into treatment research. Among the many reasons for the limited impact of previous proposals has been the absence of a clear set of guidelines for selecting candidate outcomes. This paper is the result of the deliberations of a panel of substance abuse treatment and research experts convened by the National Institute on Drug Abuse to discuss appropriate outcome measures for clinical trials of substance abuse treatments. This paper provides an overview of previous recommendations and outlines specific guidelines for consideration of candidate outcomes. A list of outcomes meeting those guidelines is described and illustrated in detail with two outcomes: craving and quality of life. The paper concludes with specific recommendations for moving beyond the outcome listing offered in this paper to promote the programmatic incorporation of these outcomes into treatment research.
Addiction Treatment; Clinical Outcomes; Measures; Recommendations
DSM-IV drug use disorders, a major public health problem, are highly comorbid with other psychiatric disorders, but little is known about the role of this comorbidity when studied prospectively in the general population.
Determine the role of comorbid psychopathology in the three-year persistence of drug use disorders.
Secondary data analysis using Waves 1 (2001-2) and 2 (2004-5) of the National Epidemiologic Survey on Alcohol and Related Conditions.
Respondents with current DSM-IV drug use disorder at Wave 1 who participated in Wave 2 (N=613).
AUDADIS-IV obtained DSM-IV Axis I and II diagnoses. Persistent drug use disorder was defined as meeting full criteria for any drug use disorder between Waves 1 and 2.
Drug use disorders persisted in 30.9% of respondents. No Axis I disorders predicted persistence. Antisocial (OR=2.75; 95% CI=1.27–5.99), borderline (OR=1.91; 95% CI=1.06–3.45) and schizotypal (OR=2.77; 95% CI=1.42–5.39) personality disorders were significant predictors of persistent drug use disorders, controlling for demographics, psychiatric comorbidity, family history, treatment and number of drug use disorders. Deceitfulness and lack of remorse were the strongest antisocial criteria predictors of drug use disorder persistence, identity disturbance and self-damaging impulsivity were the strongest borderline criteria predictors, and ideas of reference and social anxiety were the strongest schizotypal criteria predictors.
Antisocial, borderline and schizotypal personality disorders are specific predictors of drug use disorder persistence over a three-year period.
Drug Dependence; Drug Abuse; Axis I disorders; Axis II disorders; Personality Disorders; Drug Persistence; Chronic Drug Use Disorder
Previous research suggests that various types of childhood maltreatment frequently co-occur and confer risk for multiple psychiatric diagnoses. This non-specific pattern of risk may mean that childhood maltreatment increases vulnerability to numerous specific psychiatric disorders through diverse, specific mechanisms or that childhood maltreatment engenders a generalised liability to dimensions of psychopathology. Although these competing explanations have different implications for intervention, they have never been evaluated empirically.
We used a latent variable approach to estimate the associations of childhood maltreatment with underlying dimensions of internalising and externalising psychopathology and with specific disorders after accounting for the latent dimensions. We also examined gender differences in these associations.
Data were drawn from a nationally representative survey of 34 653 US adults. Lifetime DSM-IV psychiatric disorders were assessed using the AUDADIS-IV. Physical, sexual and emotional abuse and neglect were assessed using validated measures. Analyses controlled for other childhood adversities and sociodemographics.
The effects were fully mediated through the latent liability dimensions, with an impact on underlying liability levels to internalising and externalising psychopathology rather than specific psychiatric disorders. Important gender differences emerged with physical abuse associated only with externalising liability in men, and only with internalising liability in women. Neglect was not significantly associated with latent liability levels.
The association between childhood maltreatment and common psychiatric disorders operates through latent liabilities to experience internalising and externalising psychopathology, indicating that the prevention of maltreatment may have a wide range of benefits in reducing the prevalence of many common mental disorders. Different forms of abuse have gender-specific consequences for the expression of internalising and externalising psychopathology, suggesting gender-specific aetiological pathways between maltreatment and psychopathology.
Epidemiological studies of categorical mental disorders consistently report that gender differences exist in many disorder prevalence rates, and that disorders are often comorbid. Can a dimensional multivariate liability model be developed to clarify how gender impacts diverse, comorbid mental disorders? We pursued this possibility in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N = 43,093). Gender differences in prevalence were systematic such that women showed higher rates of mood and anxiety disorders and men showed higher rates of antisocial and substance use disorders. We next investigated patterns of disorder comorbidity and found that a dimensional internalizing (mood and anxiety)-externalizing (antisocial and substance use) liability model fit the data well. This model was gender invariant, indicating that observed gender differences in prevalence rates originate from women and men's different average standings on latent internalizing and externalizing liability dimensions. As hypothesized, women showed a higher mean level of internalizing while men showed a higher mean level of externalizing. We discuss implications of these findings for understanding gender differences in psychopathology and for classification and intervention.
comorbidity; gender differences; internalizing-externalizing; prevalence rates
To examine prevalence, correlates, comorbidity and treatment-seeking among individuals with a lifetime major depressive episode (MDE) with and without atypical features.
Data were derived from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions, a large cross-sectional survey of a representative sample (N = 43,093) of the U.S. population, which assessed psychiatric disorders using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). Comparison groups were defined based on the presence or absence of hypersomnia or hyperphagia in individuals who meet criteria for lifetime DSM-IV MDE.
The presence of atypical features during a MDE was associated with greater rates of lifetime psychiatric comorbidity, including alcohol abuse, drug dependence, dysthymia, social anxiety disorder, specific phobia and any personality disorder (PD), except antisocial PD, than MDE without atypical features. Compared with the later group, MDE with atypical features was associated with female gender, younger age of onset, more MDEs, greater episode severity and disability, higher rates of family history of depression, bipolar I disorder, suicide attempts, and larger mental health treatment-seeking rates.
Our data provide further evidence for the clinical significance and validity of this depressive specifier. Based on the presence of any of the two reversed vegetative symptoms during an MDE most of the commonly cited validators of atypical depression were confirmed in our study. MDE with atypical features may be more common, severe, and impairing than previously documented.
Major depression; atypical features; vegetative symptoms
Replicability is a crucial element of good science, particularly so when the subject matter is sensitive and political. Therefore, we welcome close scrutiny of our brief report in the Annals of Epidemiology in 2011, “Adolescent Marijuana Use from 2002 to 2008: Higher in States with Medical Marijuana Laws, Cause Still Unclear.” We were glad to see that Harper et al. (1) were able to replicate our results showing that states with medical marijuana laws (MML) showed greater rates of marijuana use among their residents during 2002 to 2008 and that states that passed MML after 2002 already had greater use among their residents before they passed the law. However, we have several concerns with the additional analyses run by Harper et al. and further concerns with the way their results were presented. We summarize our concerns in this commentary.
Marijuana is the most frequently used illicit substance in the United States. Little is known of the role that macro-level factors, including community norms and laws related to substance use, play in determining marijuana use, abuse and dependence. We tested the relationship between state-level legalization of medical marijuana and marijuana use, abuse, and dependence.
We used the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a national survey of adults aged 18+ (n=34,653). Selected analyses were replicated using the National Survey on Drug Use and Health (NSDUH), a yearly survey of ~68,000 individuals aged 12+. We measured past-year cannabis use and DSM-IV abuse/dependence.
In NESARC, residents of states with medical marijuana laws had higher odds of marijuana use (OR: 1.92; 95% CI: 1.49-2.47) and marijuana abuse/dependence (OR: 1.81; 95% CI: 1.22-2.67) than residents of states without such laws. Marijuana abuse/dependence was not more prevalent among marijuana users in these states (OR: 1.03; 95% CI: 0.67-1.60), suggesting that the higher risk for marijuana abuse/dependence in these states was accounted for by higher rates of use. In NSDUH, states that legalized medical marijuana also had higher rates of marijuana use.
States that legalized medical marijuana had higher rates of marijuana use. Future research needs to examine whether the association is causal, or is due to an underlying common cause, such as community norms supportive of the legalization of medical marijuana and of marijuana use.
marijuana; community norms; medical marijuana laws; substance use disorders; legalization