Introduction and Aims
This paper proposes an approach for evaluating the validity of alternative low-risk drinking guidelines.
Design and Methods
Twenty-seven alternative guidelines were evaluated in terms of their ability to predict 9 measures of concurrent and prospective alcohol-related harm, using longitudinal data from a nationally representative sample of U.S. adults (n=26,438 to 12,339 depending upon outcome). Parameters compared included sensitivity, specificity, adjusted odds ratios and measures of model fit.
Performance varied by harm. The guidelines that best predicted concurrent alcohol-related harm comprised daily-only limits of 4/3 drinks for men/women, but gender-invariant limits of 4/4 drinks also performed well. Adding weekly limits did little to improve the prediction of concurrent harm. The guidelines that best predicted prospective harm comprised daily limits of 4/4 drinks combined with weekly limits of 14 drinks for men and 7 drinks for women, with weekly limits of 14/14 drinks running second. When concurrent and incident harms were aggregated, daily-only limits of 4/3 drinks performed nearly on a par with the combination of 14/14 drinks per week and 4/3 drinks per day.
This paper supported gender-specific daily limits and suggested that optimal guidelines might take daily limits from analyses of concurrent harms and weekly limits from analyses of prospective harms.
This paper illustrates a mechanism for validating the ability of low-risk drinking guidelines to accurately predict a range of alcohol-related harms, whereby countries could use their own data on consumption and its association with harm to evaluate their low-risk drinking guidelines.
drinking guidelines; alcohol-related harm; validity; prediction
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
Although treatment of depression has increased in recent years, long delays commonly separate disorder onset from first treatment contact.
This study evaluates the effects of psychiatric comorbidities and socio-demographic characteristics on lifetime treatment seeking and speed to first treatment contact for major depressive disorder (MDD).
A cross-sectional epidemiological survey including retrospective structured assessments of DSM-IV MDD and other psychiatric disorders, respondent age at disorder onset, and age at first treatment contact.
A nationally representative sample of 5,958 adults aged ≥18 years residing in households and group quarters who met lifetime criteria for MDD.
The percentage of respondents with lifetime MDD who reported ever seeking treatment is reported overall and stratified by sociodemographic characteristics. Unadjusted and adjusted hazard ratios are presented of time to first depression treatment seeking by sociodemographic characteristics and comorbid psychiatric disorders.
A majority (61.3%) of respondents with MDD reported having sought treatment for depression at some point in their lives. Time to first depression treatment contact was significantly related to the occurrence of comorbid panic disorder (AHR=2.01, 95%CI=1.69–2.39), generalized anxiety disorder (AHR=1.55, 95%CI=1.33–1.81), drug dependence (AHR=1.54, 95%CI=1.06–2.26), dysthymic disorder (AHR=1.54, 95%CI=1.35–1.76), and PTSD (AHR=1.34, 95%CI=1.13–1.59) and inversely related to male sex (AHR=0.74, 95%CI=0.66–0.82) and black race/ethnicity (AHR=0.69, 95%CI=0.59–0.81).
Comorbid psychiatric disorders, especially panic, generalized anxiety, substance use, and dysthymic disorders, appear to play an important role in accelerating treatment seeking for MDD. Outreach efforts should include a focus on depressed individuals without complicating psychiatric comorbidities.
Depression; Treatment Seeking
Item response theory (IRT) was used to determine whether DSM-IV alcohol abuse and dependence and consumption criteria were arrayed along a continuum of severity.
Data came from a large, nationally representative sample of the U.S. adult population.
DSM-IV alcohol abuse and dependence criteria formed a continuum of alcohol use disorder severity along with the drinking 5+/4+ at least once a week in the past year criterion. Criteria were invariant across sex, race-ethnicity, and age subgroups.
The drinking 5+/4+ high-risk drinking pattern was identified as a suitable criterion for future classifications of DSM-IV alcohol use disorder. Some dependence criteria were among the least severe criteria, and some abuse criteria were among the most severe, findings that question the validity of DSM-IV abuse and dependence categories as distinct entities and that do not support the assumption of abuse as prodromal to dependence. Physical dependence and addiction were identified as defining elements of the continuum. Further research examining their dimensional properties and relationships to high-risk drinking patterns appears warranted. An approach highlighting a more important role of consumption in future classifications of alcohol use disorder defined broadly to encompass all alcohol-related harm, including addiction and physical dependence is discussed.
Alcohol use disorder; IRT analysis; addiction; physical dependence; high-risk drinking patterns
Trauma exposure and posttraumatic stress disorder (PTSD) may increase risk for medical conditions in older adults. We present findings on past-year medical conditions associated with lifetime trauma exposure, and full and partial PTSD, in a nationally representative sample of U.S. older adults.
Design, Setting, Participants, and Measurements
Face-to-face diagnostic interviews were conducted with 9,463 adults aged 60 and older in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression analyses adjusting for sociodemographics and psychiatric comorbidity evaluated associations between PTSD status and past-year medical disorders; linear regression models evaluated associations with past-month physical functioning.
After adjustment for sociodemographic characteristics and comorbid lifetime mood, anxiety, substance use, attention-deficit/hyperactivity, and personality disorders, respondents with lifetime PTSD were more likely than trauma controls to report being diagnosed by a healthcare professional with hypertension, angina pectoris, tachycardia, other heart disease, stomach ulcer, gastritis, and arthritis (odds ratios [ORs]=1.3–1.8); they also scored lower on a measure of physical functioning than controls and respondents with partial PTSD. Respondents with lifetime partial PTSD were more likely than controls to report past-year diagnoses of gastritis (OR=1.7), angina pectoris (OR=1.5), and arthritis (OR=1.4), and reported worse physical functioning. Number of lifetime traumatic event types was associated with most of the medical conditions assessed; adjustment for these events reduced the magnitudes of and rendered non-significant most associations between PTSD status and medical conditions.
Older adults with lifetime PTSD have elevated rates of several physical health conditions, many of which are chronic disorders of aging, and poorer physical functioning. Older adults with lifetime partial PTSD have elevated rates of gastritis, angina pectoris, and arthritis, and poorer physical functioning.
posttraumatic stress disorder; medical; comorbidity; epidemiology; older adults
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
Alcohol has been linked to health disparities between races in the US; however, race-specific alcohol-attributable mortality has never been estimated. The objective of this article is to estimate premature mortality attributable to alcohol in the US in 2005, differentiated by race, age and sex for people 15 to 64 years of age.
Methods and Findings
Mortality attributable to alcohol was estimated based on alcohol-attributable fractions using indicators of exposure from the National Epidemiologic Survey on Alcohol and Related Conditions and risk relations from the Comparative Risk Assessment study. Consumption data were corrected for undercoverage (the observed underreporting of alcohol consumption when using survey as compared to sales data) using adult per capita consumption from WHO databases. Mortality data by cause of death were obtained from the US Department of Health and Human Services. For people 15 to 64 years of age in the US in 2005, alcohol was responsible for 55,974 deaths (46,461 for men; 9,513 for women) representing 9.0% of all deaths, and 1,288,700 PYLL (1,087,280 for men; 201,420 for women) representing 10.7% of all PYLL. Per 100,000 people, this represents 29 deaths (29 for White; 40 for Black; 82 for Native Americans; 6 for Asian/Pacific Islander) and 670 PYLL (673 for White; 808 for Black; 1,808 for Native American; 158 for Asian/Pacific Islander). Sensitivity analyses showed a lower but still substantial burden without adjusting for undercoverage.
The burden of mortality attributable to alcohol in the US is unequal among people of different races and between men and women. Racial differences in alcohol consumption and the resulting harms explain in part the observed disparities in the premature mortality burden between races, suggesting the need for interventions for specific subgroups of the population such as Native Americans.
Desire for death is not generally considered a harbinger of more severe suicidal behavior and is not routinely included in suicide research and assessment interviews. We aimed to compare desire for death and suicidal ideation as clinical markers for suicide attempts.
Using data from two nationally representative surveys (n=42,862 and n=43,093 respectively), we examined whether desire for death predicts suicide attempts. We compared the odds ratio (OR) and “Number Needed to be Exposed for one additional person to be Harmed” [NNEH] for lifetime suicide attempts among those with desire for death but no suicidal ideation; those with suicidal ideation but no desire for death, and those with both desire for death and suicidal ideation, compared to those with neither desire for death nor suicidal ideation.
The risk for lifetime suicide attempt was similar among those with lifetime desire for death with no suicidal ideation and those with lifetime suicidal ideation with no desire for death. Respondents with both lifetime desire for death and suicidal ideation had the highest risk for lifetime suicide attempts.
Cross-sectional design; self-reported suicidal ideation/attempts.
Querying individuals on desire for death has the same value as assessing suicidal ideation to examine risk for suicide attempt. A combination of desire for death and suicidal ideation is the best predictor for suicide attempts. This is of high clinical relevance since we suggest that desire for death should be included as a potential clinical marker of suicidality in clinical assessments.
Attempted suicide; suicidal ideation; desire for death
This study examined associations between lifetime trauma exposures, PTSD and partial PTSD, and past-year medical conditions in a nationally representative sample of U.S. adults.
Face-to-face interviews were conducted with 34,653 participants in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression analyses evaluated associations of trauma exposure, PTSD and partial PTSD with respondent-reported medical diagnoses.
After adjustment for sociodemographic characteristics and comorbid Axis I and II disorders, respondents with full PTSD were more likely than traumatized respondents without full or partial PTSD (comparison group) to report diagnoses of diabetes mellitus, noncirrhotic liver disease, angina pectoris, tachycardia, hypercholesterolemia, other heart disease, stomach ulcer, HIV seropositivity, gastritis, and arthritis (odds ratios [ORs]=1.2-2.5). Respondents with partial PTSD were more likely than the comparison group to report past-year diagnoses of stomach ulcer, angina pectoris, tachycardia, and arthritis (ORs=1.3-1.6). Men with full and partial PTSD were more likely than controls to report diagnoses of hypertension (both ORs=1.6), and both men and women with PTSD (ORs=1.8 and 1.6, respectively), and men with partial PTSD (OR=2.0) were more likely to report gastritis. Total number of lifetime traumatic event types was associated with many assessed medical conditions (ORs=1.04-1.16), reducing the magnitudes and rendering non-significant some of the associations between PTSD status and medical conditions.
Greater lifetime trauma exposure and PTSD are associated with numerous medical conditions, many of which are stress-related and chronic, in U.S. adults. Partial PTSD is associated with intermediate odds of some of these conditions.
Comorbidity; epidemiology; posttraumatic stress disorder; medical illness; cardiovascular
Evidence-based changes planned for DSM-5 substance use disorders (SUDs) include combining dependence and three of the abuse criteria into one disorder and adding a criterion indicating craving. Because DSM-IV did not include a category for nicotine abuse, little empirical support is available for aligning the nicotine use disorder criteria with the DSM-5 criteria for other SUDs.
Latent variable analyses, likelihood ratio tests (LRT) and bootstrap tests were used to explore the unidimensionality, psychometric properties and information of the nicotine criteria.
A sample of household residents selected from the Israeli population register yielded 727 lifetime cigarette smokers.
DSM-IV nicotine dependence criteria and proposed abuse and craving criteria, assessed with a structured interview.
Three abuse criteria (hazardous use, social/interpersonal problems, and neglect roles) were prevalent among smokers, formed a unidimensional latent trait with nicotine dependence criteria, were intermixed with dependence criteria across the severity spectrum, and significantly increased the diagnostic information over the dependence-only model. LRT results also supported including the abuse criteria (Χ23=259.63, p<0.0001). A craving criterion was shown to fit well with the other criteria.
Similar to findings from research on other substances, nicotine dependence, abuse, and craving criteria formed a single factor. The results support alignment of nicotine criteria with those for alcohol and drug use disorders in DSM-5.
Item Response Theory; nicotine use disorders; nicotine dependence; DSM-IV; DSM-5; Israel
To assess the national incidence and mental health correlates of recent intimate partner violence.
Data from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (n=34,653) were analyzed focusing on adults who were married, recently married, or in a romantic relationship (n=25,626). Intimate partner violence (n=1,608) included minor and severe forms of violence. The main outcome measures were the prevalence of intimate partner violence and the association of intimate partner violence with new onset of Axis I disorders.
During the past year, 5.8% of women and 5.6% of men reported being victims of intimate partner violence. New onset axis I disorders were significantly more common among intimate partner violence victims (20.9%) than non-victims (9.4%) (OR=2.55, 2.19–2.97) and were related to frequency of violent acts.
Intimate partner violence is common and victimization, especially if recurrent, markedly increases the risk for developing several psychiatric disorders.
While it is well known that personality disorders are associated with trauma exposure and PTSD, limited nationally representative data are available on DSM-IV personality disorders that co-occur with posttraumatic stress disorder (PTSD) and partial PTSD.
Face-to-face interviews were conducted with 34,653 adults participating in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression analyses controlling for sociodemographics and additional psychiatric comorbidity evaluated associations of PTSD and partial PTSD with personality disorders.
Prevalence rates of lifetime PTSD and partial PTSD were 6.4% and 6.6%, respectively. After adjustment for sociodemographic characteristics and additional psychiatric comorbidity, respondents with full PTSD were more likely than trauma controls to meet criteria for schizotypal, narcissistic, and borderline personality disorders (ORs=2.1–2.5); and respondents with partial PTSD were more likely than trauma controls to meet diagnostic criteria for borderline (OR=2.0), schizotypal (OR=1.8), and narcissistic (OR=1.6) PDs. Women with PTSD were more likely than controls to have obsessive-compulsive PD. Women with partial PTSD were more likely than controls to have antisocial PD; and men with partial PTSD were less likely than women with partial PTSD to have avoidant PD.
PTSD and partial PTSD are associated with borderline, schizotypal, and narcissistic personality disorders. Modestly higher rates of obsessive-compulsive PD were observed among women with full PTSD, and of antisocial PD among women with partial PTSD.
Posttraumatic stress disorder; personality disorders; epidemiology; comorbidity
To compare the 12-month prevalence of psychiatric disorders in Asian Americans/Pacific Islanders in contrast to non–Hispanic whites; and further compare persistence and treatment-seeking rates for psychiatric disorders among Asian American/Pacific Islanders and non-Hispanic whites, analyses from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions, Wave 1 (n =43,093) were conducted for the subsample of 1,332 Asian Americans/Pacific Islanders (596 men and 736 women) and 24,507 non-Hispanic whites (10,845 men and 13,662 women). The past 12-month prevalence for any psychiatric disorder was significantly lower in Asian American/Pacific Islander males and females than non-Hispanic white males and females. Asian American/Pacific Islander males were less likely than non-Hispanic white males to have any mood, anxiety, substance use, and personality disorders, whereas the prevalence of mood disorders among Asian American/Pacific Islander females did not differ from those of non-Hispanic white females. In some cases, such as drug use disorders, both male and female Asian Americans/Pacific Islanders were more likely to have more persistent disorders than non-Hispanic whites. Compared to non-Hispanic white females, Asian American/Pacific Islander females had lower rates of treatment-seeking for any mood/anxiety disorders. Although less prevalent than among non-Hispanic whites, psychiatric disorders are not uncommon among Asian Americans/Pacific Islanders. The lower treatment seeking rates for mood/anxiety disorders in Asian American/Pacific Islander females underscore the unmet needs for psychiatric service among this population.
epidemiology; psychiatric disorders; Asian American; Pacific Islanders; mental health; treatment utilization
This study aims to estimate general and racial-ethnic specific cumulative probability of developing dependence among nicotine, alcohol, cannabis or cocaine users, and to identify predictors of transition to substance dependence.
Analyses were done for the subsample of lifetime nicotine (n=15,918), alcohol (n=28,907), cannabis (n=7,389) or cocaine (n=2,259) users who participated in the first and second wave of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Discrete-time survival analyses were implemented to estimate the cumulative probability of transitioning from use to dependence and to identify predictors of transition to dependence.
The cumulative probability estimate of transition to dependence was 67.5% for nicotine users, 22.7% for alcohol users, 20.9% for cocaine users, and 8.9% for cannabis users. Half of the cases of dependence on nicotine, alcohol, cannabis and cocaine were observed approximately 27, 13, 5 and 4 years after use onset, respectively. Significant racial-ethnic differences were observed in the probability of transition to dependence across the four substances. Several predictors of dependence were common across the four substances assessed.
Transition from use to dependence was highest for nicotine users, followed by cocaine, alcohol and cannabis users. Transition to cannabis or cocaine dependence occurred faster than transition to nicotine or alcohol dependence. The existence of common predictors of transition dependence across substances suggests that shared mechanisms are involved. The increased risk of transition to dependence among individuals from minorities or those with psychiatric or dependence comorbidity highlights the importance of promoting outreach and treatment of these populations.
nicotine; alcohol; cannabis; cocaine; dependence; racial-ethnic groups; discrete-time time survival analyses
Borderline personality disorder (BPD) shows high levels of comorbidity with an array of psychiatric disorders. The meaning and causes of this comorbidity are not fully understood. Our objective was to investigate and clarify the complex comorbidity of BPD by integrating it into the structure of common mental disorders.
We conducted exploratory and confirmatory factor analyses on diagnostic interview data from a representative U. S. population-based sample of 34,653 civilian, non-institutionalized individualized aged 18 and older. We modeled the structure of lifetime DSM-IV diagnoses of borderline and antisocial personality disorders, major depressive disorder, dysthymic disorder, panic disorder with agoraphobia, social phobia, specific phobia, generalized anxiety disorder, post-traumatic stress disorder, alcohol dependence, nicotine dependence, marijuana dependence, and any other drug dependence.
In both women and men, the internalizing-externalizing structure of common mental disorders captured the comorbidity among all disorders including BPD. While BPD was unidimensional in terms of its symptoms, BPD as a disorder showed associations with both the distress sub-factor of the internalizing dimension and the externalizing dimension.
The complex patterns of comorbidity observed with BPD represent connections to other disorders at the level of latent internalizing and externalizing dimensions. BPD is meaningfully connected with liabilities shared with common mental disorders, and these liability dimensions provide a beneficial focus for understanding BPD’s comorbidity, etiology, and treatment.
Borderline personality disorder; internalizing-externalizing; latent structure; comorbidity
Research focusing on the development of a dimensional representation of DSM-IV nicotine dependence is scarce and prior research has not assessed the role of nicotine use criteria in that a dimensional representation, nor the invariance of the DSM-IV nicotine dependence criteria across important population subgroups.
Using a large, representative sample of the U.S. population, this study utilized item response theory (IRT) analyses to explore the dimensionality of DSM-IV nicotine dependence criteria and several candidate criteria for cigarette use among past-year cigarette smokers (n = 10,163).
Factor analyses demonstrated the unidimensionality of nicotine dependence criteria and IRT analyses demonstrated good fit of the observed responses and the underlying, unobserved latent trait of dependence severity. The model containing all seven DSM-IV dependence criteria, along with the consumption criterion of smoking at least a quarter of a pack of cigarettes in a day in the past year, was identified as the best-fitting model. No differential criterion functioning was shown across sex, race-ethnicity, and age subgroups.
Major implications of this study are discussed in terms of the addition of a dimensional representation of nicotine dependence to pre-existing categorical representations of the disorder in the DSM-V, and the need for a nicotine consumption criterion to improve representations of nicotine dependence severity.
Nicotine dependence; Item response theory; Nicotine use criterion; Psychiatric assessment; DSM-V revision
To compare the prevalence of suicidal ideation/attempts among Hispanic subgroups in the US in 1991–1992 and 2001–2002, and identify high-risk groups.
Data were drawn from the 1991–1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES, n=42,862) and the 2001–2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC,n=43,093), two nationally representative surveys of individuals aged 18 years and older.
1) Puerto Ricans are the Hispanic ethnic subgroup with the highest rates of suicide attempts; 2) 45- to 64-year-old Puerto Rican women are a high- risk group for suicide attempts; 3) Over the 10 year period between the two surveys, the lifetime prevalence of suicide attempts significantly increased among 18- to 24-year-old Puerto Rican women and Cuban men, and among 45- to 64-year-old Puerto Rican men.
Hispanics in the US are not a homogeneous group. We identify high-risk groups among Hispanics. Specific interventions for subgroups of Hispanics at high risk for suicidal behaviors may be required.
Attempted Suicide; Epidemiology; Prevalence; Health Surveys; Ethnic Groups; Age Groups
The present study used data from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (n=34,653) to examine lifetime Axis I psychiatric comorbidity of posttraumatic stress disorder (PTSD) in a nationally representative sample of U.S. adults. Lifetime prevalences±standard errors of PTSD and partial PTSD were 6.4%±0.18 and 6.6%±0.18, respectively. Rates of PTSD and partial PTSD were higher among women (8.6%±0.26 and 8.6%±0.26) than men (4.1%±0.19 and 4.5%±0.21). Respondents with both PTSD and partial PTSD most commonly reported unexpected death of someone close, serious illness or injury to someone close, and sexual assault as their worst stressful experiences. PTSD and partial PTSD were associated with elevated lifetime rates of mood, anxiety, and substance use disorders, and suicide attempts. Respondents with partial PTSD generally had intermediate odds of comorbid Axis I disorders and psychosocial impairment relative to trauma controls and full PTSD.
posttraumatic stress disorder; epidemiology; comorbidity; mood disorders; anxiety disorders; substance use disorders
To estimate the general and racial-ethnic specific cumulative probability of remission from nicotine alcohol cannabis or cocaine dependence, and to identify predictors of remission across substances.
Data were collected from structured diagnostic interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule – DSM-IV version.
The 2001–2002 NESARC surveyed a nationally representative sample from USA adults (n=43,093) selected in a three-stage sampling design.
The subsamples of individuals with lifetime DSM-IV diagnosis of dependence on nicotine (n=6,937), alcohol (n=4,781), cannabis (n=530) and cocaine (n=408).
Cumulative probability estimates of dependence remission for the general population and across racial-ethnic groups. Hazard ratios for remission from dependence.
Lifetime cumulative probability estimates of dependence remission were 83.7% for nicotine, 90.6% for alcohol, 97.2% for cannabis, and 99.2% for cocaine. Half of the cases of nicotine, alcohol, cannabis and cocaine dependence remitted approximately 26, 14, 6 and 5 years after dependence onset, respectively. Males, Blacks and individuals with diagnosis of personality disorders and history of substance use comorbidity exhibited lower hazards of remission for at least two substances.
A significant proportion of individuals with dependence on nicotine, alcohol, cannabis or cocaine achieve remission at some point in their lifetime, although the probability and time to remission varies by substance and racial-ethnic group. Several predictors of remission are shared by at least two substances, suggesting that the processes of remission overlap. The lower rates of remission of individuals with comorbid personality or substance use disorders highlight the need of providing coordinated psychiatric and substance abuse interventions.
The purpose of this study was to examine the effects of specific personality disorder co-morbidity on the course of major depressive disorder in a nationally-representative sample.
Data were drawn from 1,996 participants in a national survey. Participants who met criteria for major depressive disorder at baseline in face-to-face interviews (2001–2002) were re-interviewed three years later (2004–2005) to determine persistence and recurrence. Predictors included all DSM-IV personality disorders. Control variables included demographic characteristics, other Axis I disorders, family and treatment histories, and previously established predictors of the course of major depressive disorder.
15.1% of participants had persistent major depressive disorder and 7.3% of those who remitted had a recurrence. Univariate analyses indicated that avoidant, borderline, histrionic, paranoid, schizoid, and schizotypal personality disorders all elevated the risk for persistence. With Axis I co-morbidity controlled, all but histrionic personality disorder remained significant. With all other personality disorders controlled, borderline and schizotypal remained significant predictors. In final, multivariate analyses that controlled for age at onset of major depressive disorder, number of previous episodes, duration of current episode, family history, and treatment, borderline personality disorder remained a robust predictor of major depressive disorder persistence. Neither personality disorders nor other clinical variables predicted recurrence.
In this nationally-representative sample of adults with major depressive disorder, borderline personality disorder robustly predicted persistence, a finding that converges with recent clinical studies. Personality psychopathology, particularly borderline personality disorder, should be assessed in all patients with major depressive disorder, considered in prognosis, and addressed in treatment.
Although clinical studies have documented that specific anxiety disorders are associated with impaired psychosocial functioning, little is known regarding their comparative effects on health-related quality of life within a general population. The current analysis compares health-related quality of life in a U.S. community-dwelling sample of adults with DSM-IV social anxiety disorder (SAD), generalized anxiety disorders (GAD), panic disorder (PD), and specific phobia (SP).
Face-to-face survey of a U.S. nationally representative sample of over 43,000 adults aged 18 years and older residing in households and group quarters. Prevalence of DSM-IV anxiety disorders and relative associations with health-related quality of life indicators were examined.
Roughly 9.8% of respondents met diagnostic criteria for at least one 12-month DSM-IV anxiety disorder which, relative to the non-anxiety-disordered general population, were each associated with lower personal income, increased rates of 12-month physical conditions, and greater numbers of Axis I and Axis II DSM-IV psychiatric conditions. After adjusting for socio-demographic and clinical correlates including other anxiety disorders, GAD was associated with significant decrements in the SF-12 Mental Component Summary score. In similar models, GAD and to a lesser extent PD were significantly associated with impairment in social functioning, role emotional, and mental health SF subscales.
GAD, followed by PD, appears to exact significant and independent tolls on health-related quality of life. Results underscore the importance of prompt and accurate clinical identification and improving access to effective interventions for these disorders.
To examine the prevalence of chronic major depressive disorder (CMDD) and dysthymic disorder (DD), their sociodemographic correlates, patterns of 12-month and lifetime psychiatric comorbidity, lifetime risk factors, psychosocial functioning, and mental health service utilization.
Face-to-face interviews were conducted in the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093).
The 12-month and lifetime prevalence were greater for CMDD (1.5% and 3.1%) than for DD (0.5% and 0.9%). Individuals with CMDD and DD shared most sociodemographic correlates and lifetime risk factors for MDD. Individuals with CMDD and DD had almost identically high rates of Axis I and Axis II comorbid disorders. However, individuals with CMDD received higher rates of all treatment modalities than individuals with DD.
Individuals with CMDD and DD share many sociodemographic correlates, comorbidity patterns, risk factors, and course. Individuals with chronic depressive disorders, especially those with DD, continue to face substantial unmet treatment needs.
dysthymic disorder; chronicity; major depressive disorder; epidemiology
There is growing concern that results of tightly controlled clinical trials may not generalize to broader community samples. To assess the proportion of community-dwelling adults with cannabis dependence who would have been eligible for a typical cannabis dependence treatment study, we applied a standard set of eligibility criteria commonly used in cannabis 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). Approximately eighty percent (80%) of the community sample of adults with a diagnosis of cannabis dependence (n=133) would be excluded from participating in clinical trials by one or more of the common eligibility criteria. Individual study criteria excluded from 0% to 41.0% of the community sample. Legal problems, other illicit drug use disorders, and current use of fewer than 5 joints/week excluded the largest percentage of individuals. These results extend to cannabis dependence concerns that typical clinical trials likely exclude most community dwelling adults with the disorder. The results also support the notion that clinical trials tend to recruit highly selective samples, rather than adults who are representative of typical patients. Clinical trials should carefully evaluate the effects of eligibility criteria on the generalizability of their results. Even in efficacy trials, stringent exclusionary criteria could limit the representativeness of study results.
epidemiology; generalizability; cannabis dependence; clinical trials; eligibility criteria; inclusion criteria; exclusion criteria