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1.  Gender, HIV status, and psychiatric disorders: Results from the national epidemiologic study on alcohol and related conditions 
The Journal of clinical psychiatry  2011;73(3):10.4088/JCP.10m06304.
Objective
More than thirty years after the onset of the HIV epidemic, there is no information on the prevalence of psychiatric disorders among HIV-positive individuals in the general population. We sought to compare the prevalence of 12-month psychiatric disorders among HIV-positive and HIV-negative adults stratified by sex, and to examine the differential increase in risk of a psychiatric disorder as a function of the interaction of sex and HIV status.
Methods
Face-to-face interviews conducted between 2004 and 2005 with participants in a large nationally representative sample of US adults (34,653).
Results
When compared with their HIV-negative same sex counterparts, HIV-positive men were more likely to have any mood disorder (Odds ratio [OR]=6.10; 95%; Confidence interval [CI] =2.99–12.44), major depressive disorder/dysthymia (OR=3.77; 95% CI=1.16–12.27), any anxiety disorder (OR=4.02; 95% CI=2.12–7.64), and any personality disorder (OR=2.50; 95% CI=1.34–4.67) In relation to their same sex HIV-negative counterparts, the effect of HIV status on the odds of any mood disorder (OR=7.17; 95% CI=2.52–20.41), any anxiety disorder (OR=3.45; 95% CI=1.27–9.38) and any personality disorder (OR=2.66; 95% CI=1.16–6.10) was significantly greater for men than women.
Conclusions
HIV status was significantly more strongly associated with psychiatric disorders in men than women. HIV-positive men had a higher prevalence than HIV-negative men of most psychiatric disorders. By contrast, HIV-positive women were not significantly more likely than HIV-negative women to have psychiatric disorders.
doi:10.4088/JCP.10m06304
PMCID: PMC3816377  PMID: 22053858
HIV; psychiatric disorders; gender; epidemiology
2.  Prevalence, correlates, comorbidity and treatment-seeking among individuals with a lifetime major depressive episode with and without atypical features: Results from the National Epidemiologic Survey on Alcohol and Related Conditions 
Objective
To examine prevalence, correlates, comorbidity and treatment-seeking among individuals with a lifetime major depressive episode (MDE) with and without atypical features.
Methods
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.
Results
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.
Conclusions
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.
doi:10.4088/JCP.10m06227
PMCID: PMC3475327  PMID: 21939615
Major depression; atypical features; vegetative symptoms
3.  A new definition of early age at onset in alcohol dependence 
Drug and alcohol dependence  2009;108(0):43-48.
Objective
The accurate cut-off of an early onset of alcohol dependence is unknown. The objectives of this analysis are (1) to confirm that ages at onset variability in alcohol dependence is best described as a two sub-groups entity, (2) to define the most appropriate cut-off, and (3) to test the relevancy of such distinction.
Method
Data were drawn the Epidemiologic Survey on Alcohol and Related Conditions (NESARC). This study focused on the 4,782 adults with lifetime alcohol dependence.
Results
The best-fit model distinguished two subgroups of age at onset of alcohol dependence, with a cut-off point at 22 years. Subjects with an earlier onset of alcohol dependence (≤22 years old) reported higher lifetime rates of specific phobia, antisocial behaviors and nearly all addictive disorders.
Conclusions
The early onset of alcohol dependence is best defined as beginning before the age of 22 years.
doi:10.1016/j.drugalcdep.2009.11.011
PMCID: PMC4313551  PMID: 20018459
NESARC; alcohol dependence; admixture test; DSM-V; age at onset
4.  Temporal Relationships between Overweight and Obesity and DSM-IV Substance Use, Mood, and Anxiety Disorders: Results from a Prospective Study 
The Journal of clinical psychiatry  2011;72(11):1494-1502.
Background
Associations between overweight and obesity and medical conditions have been extensively studied, but little is known about their relationships to psychiatric disorders.
Objective
To present nationally representative findings on the prospective relationships between overweight and obesity and DSM-IV substance use, mood and anxiety disorders.
Design, Setting and Participants
Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of 34,653 U.S. adults.
Main Outcome Measures
Incidence of DSM-IV substance use, mood and anxiety disorders and changes in BMI status during the 3-year follow-up.
Results
Regression analyses that controlled for a wide array of covariates showed that overweight and obese women were at increased risk for incident major depressive disorder (MDD) during the follow-up period. Overweight men and obese men were at decreased risk of incident drug abuse and alcohol dependence, respectively. Obese women had a decreased risk of incident alcohol abuse and drug dependence. Men with drug dependence and women with specific phobia had a decreased risk of becoming overweight or obese during the follow-up.
Limitations
The NESARC excluded adolescents and the homeless and weight was self-reported, but highly correlated with external validating data.
Conclusions
Increased risk of MDD among overweight and obese women could be attributed to stigma and greater body dissatisfaction among women in Western cultures. Overweight and obesity may serve as protective factors against developing incident substance use disorders possibly due to shared neural functions in the brain underlying addictions to numerous substances. Results are discussed in terms of their clinical implications including the need to update treatment guidelines for the management of overweight, obesity and MDD.
doi:10.4088/JCP.10m06077gry
PMCID: PMC3227748  PMID: 21457678
5.  Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)* 
Drug and alcohol dependence  2010;115(1-2):120-130.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1016/j.drugalcdep.2010.11.004
PMCID: PMC3069146  PMID: 21145178
nicotine; alcohol; cannabis; cocaine; dependence; racial-ethnic groups; discrete-time time survival analyses
6.  Suicidal ideation and suicide attempts among Hispanic subgroups in the United States: 1991–1992 and 2001–2002 
Journal of psychiatric research  2011;45(4):512-518.
Objective
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.
Method
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.
Results
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.
Conclusion
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.
doi:10.1016/j.jpsychires.2010.09.004
PMCID: PMC3032009  PMID: 20937507
Attempted Suicide; Epidemiology; Prevalence; Health Surveys; Ethnic Groups; Age Groups
8.  Stress and Alcohol 
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 influence 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.
PMCID: PMC3797525  PMID: 23584105
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
9.  The Epidemiology of Chronic Major Depressive Disorder and Dysthymic Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions 
The Journal of clinical psychiatry  2010;71(12):1645-1656.
Objective
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.
Method
Face-to-face interviews were conducted in the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093).
Results
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.
Conclusion
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.
doi:10.4088/JCP.09m05663gry
PMCID: PMC3202750  PMID: 21190638
dysthymic disorder; chronicity; major depressive disorder; epidemiology
10.  Social Anxiety Disorder and Alcohol Use Disorder Comorbidity in the National Epidemiologic Survey on Alcohol and Related Conditions 
Psychological medicine  2010;40(6):977-988.
Objective
To assess the prevalence and clinical impact of comorbid Social Anxiety Disorder (SAD) and Alcohol Use Disorders (AUD, i.e., alcohol abuse and alcohol dependence) in a nationally representative sample of adults in the United States.
Methods
Data came from a large representative sample of the United States population. Face-to-face interviews of 43,093 adults residing in households were conducted during 2001–2002. Diagnoses of mood, anxiety, alcohol and drug use disorders, and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule—DSM-IV Version.
Results
Lifetime prevalence of comorbid AUD and SAD in the general population was 2.4%. SAD was associated with significantly increased rates of alcohol dependence (OR=2.8) and alcohol abuse (OR=1.2). Among respondents with alcohol dependence, SAD was associated with significantly more mood, anxiety, psychotic, and personality disorders. Among respondents with SAD, alcohol dependence and abuse were most strongly associated with more substance use disorders, pathological gambling, and antisocial personality disorders. SAD occurred before alcohol dependence in 79.7% of comorbid cases, but comorbidity status did not influence age of onset for either disorder. Comorbid SAD was associated with increased severity of alcohol dependence and abuse. Respondents with comorbid SAD and alcohol dependence or abuse reported low rates of treatment-seeking.
Conclusions
Comorbid lifetime AUD and SAD is a prevalent dual diagnosis, associated with substantial rates of additional comorbidity, but remaining largely untreated. Future research should clarify the etiology of this comorbid presentation to better identify effective means of intervention.
doi:10.1017/S0033291709991231
PMCID: PMC2917264  PMID: 20441690
11.  The Prevalence and Correlates of Alcohol Use Disorders in the United States and Korea – A Cross-National Comparative Study 
Alcohol (Fayetteville, N.Y.)  2010;44(4):297-306.
The purpose of this study was to compare the prevalence rates of DSM-IV 12-month diagnoses of alcohol use disorders between the United States and South Korea using two large nationally representative surveys. Cross-tabulations were used to derive weighted prevalences of alcohol abuse and dependence, and odds ratio derived from linear logistic regression analyses were used to determine the relationships between alcohol abuse and dependence across sociodemographic characteristics of the general population samples. The prevalence of 12-month alcohol abuse was greater in the U.S. (5.3%) than Korea (2.0%) whereas the rate of alcohol dependence was greater in Korea (5.1%) compared with the U.S. (4.4%). The odds of abuse were significantly greater among men, and in the youngest age groups in both countries. There were increased odds of 12-month dependence among men, and those who were employed or never married in each country. Further, the rates of abuse and dependence in the U.S. and of abuse in Korea decreased as a function of age, a result that did not generalize to dependence among Koreans. The implications of the results of this study are discussed in terms of national differences between the U.S. and Korea as the result of gender roles and drinking patterns, and the need to understand the potential influence of the cultural applicability and specificity of psychiatric assessment interviews across countries.
doi:10.1016/j.alcohol.2010.02.005
PMCID: PMC2918727  PMID: 20570084
Alcohol use disorder; cross-national comparisons; prevalence; sociodemographic correlates; United States; South Korea
12.  Suicidal ideation and suicide attempts in the United States: 1991-1992 and 2001-2002 
Molecular psychiatry  2008;15(3):250-259.
The aim of the study is to compare the prevalence of suicidal ideation and attempts in the US in 1991-1992 and 2001-2002, and identify sociodemographic groups at increased risk for suicidal ideation and attempts. Data were drawn from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 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 household surveys of non-institutionalized civilians aged 18 years and older, residing in the US. The lifetime prevalence of suicide attempts remained unchanged in the US between 1991-1992 and 2001-2002. Specific groups, namely 18- to 24-year-old White and Black women, 25- to 44- year-old White women, and 45-64-year-old Native American men were identified as being at increased risk for suicide attempts. Despite prevention and treatment efforts, the lifetime prevalence of suicide attempts remains unchanged. Given the morbidity and mortality associated with suicide attempts, urgent action is needed to decrease the prevalence of suicide attempts in the US.
doi:10.1038/mp.2008.98
PMCID: PMC2825279  PMID: 18779820
Attempted Suicide; Epidemiology; Prevalence; Health Surveys; Ethnic Groups; Age Groups
13.  Sociodemographic and Psychopathologic Predictors of First Incidence of DSM-IV Substance Use, Mood, and Anxiety Disorders: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions 
Molecular psychiatry  2008;14(11):1051-1066.
The objective of this study was to present nationally representative findings on sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance, mood and anxiety disorders using the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. One-year incidence rates of DSM-IV substance, mood and anxiety disorders were highest for alcohol abuse (1.02) alcohol dependence (1.70), major depressive disorder (MDD: 1.51) and generalized anxiety disorder (GAD: 1.12). Incidence rates were significantly greater (p < 0.01) among men for substance use disorders and greater among women for mood and anxiety disorders except bipolar disorder and social phobia. Age was inversely related to all disorders. Black individuals were at decreased risk of incident alcohol abuse and Hispanic individuals were at decreased risk of GAD. Anxiety disorders at baseline more often predicted incidence of other anxiety disorders than mood disorders. Reciprocal temporal relationships were found between alcohol abuse and dependence, MDD and GAD, and GAD and panic disorder. Borderline and schizotypal personality disorders predicted most incident disorders. Incidence rates of substance, mood and anxiety disorders were comparable to or greater than rates of lung cancer, stroke, and cardiovascular disease. The greater incidence of all disorders in the youngest cohort underscores the need for increased vigilance in identifying and treating these disorders among young adults. Strong common factors and unique factors appear to underlie associations between alcohol abuse and dependence, MDD and GAD, and GAD and panic disorder. The major results of this study are discussed with regard to prevention and treatment implications.
doi:10.1038/mp.2008.41
PMCID: PMC2766434  PMID: 18427559
Incidence; epidemiology; prospective study; substance use disorders; mood disorders; anxiety disorders
14.  Violent Behavior and DSM-IV Psychiatric Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions 
Objective
To present nationally representative data on the lifetime prevalence and population estimates of violent behavior among individuals with DSM-IV psychiatric disorders.
Method
The data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions. Prevalences, population estimates, and associations of violent behavior occurring among individuals with pure, comorbid and specific DSM-IV psychiatric disorders were examined.
Results
Controlling for sociodemographic characteristics and other comorbidity, the odds of violent behavior were significantly increased (p < 0.05) among individuals with substance use disorders, pathological gambling, major depressive disorder, bipolar disorders, panic disorder with agoraphobia, specific phobia, and paranoid, schizoid, histrionic, and obsessive-compulsive personality disorders. Percentages of violent behavior among individuals with each comorbid disorders was significantly greater (p < 0.05 – p < 0.0001) than the corresponding percentages among those presenting with the pure form of each disorder. Alcohol and drug use disorders were the most significant contributors to the public health burden of violent behavior.
Conclusion
The majority of individuals with psychiatric disorders do not engage in violent behavior, and public perception associated with stereotypic violence among individuals with psychiatric disorders appears unwarranted. Elevated risks and burden of violent behavior were not equally shared across the spectrum of psychiatric disorders, with particular disorders, especially substance use disorders, contributing disproportionately to the burden. Future research should examine the circumstances under which violence among individuals with psychiatric disorders occurs with a view towards improving clinical prediction and developing more effective prevention strategies.
PMCID: PMC2922980  PMID: 18312033
Violent behavior; Psychiatric disorders; Mood and anxiety disorders; Substance use disorders; Personality disorders
15.  DSM-IV Personality Disorders and Associations with Externalizing and Internalizing Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions 
Journal of psychiatric research  2013;47(11):10.1016/j.jpsychires.2013.07.016.
Background
Although associations between personality disorders and psychiatric disorders are well established in general population studies, their association with liability dimensions for externalizing and internalizing disorders has not been fully assessed. The purpose of this study is to examine associations between personality disorders (PDs) and lifetime externalizing and internalizing Axis I disorders.
Methods
Data were obtained from the total sample of 34,653 respondents from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drawing on the literature, a 3-factor exploratory structural equation model was selected to simultaneously assess the measurement relations among DSM-IV Axis I substance use and mood and anxiety disorders and the structural relations between the latent internalizing-externalizing dimensions and DSM-IV PDs, adjusting for gender, age, race/ethnicity, and marital status.
Results
Antisocial, histrionic, and borderline PDs were strong predictors for the externalizing factor, while schizotypal, borderline, avoidant, and obsessive-compulsive PDs had significantly larger effects on the internalizing fear factor when compared to the internalizing misery factor. Paranoid, schizoid, narcissistic, and dependent PDs provided limited discrimination between and among the three factors. An overarching latent factor representing general personality dysfunction was significantly greater on the internalizing fear factor followed by the externalizing factor, and weakest for the internalizing misery factor.
Conclusion
Personality disorders offer important opportunities for studies on the externalizing-internalizing spectrum of common psychiatric disorders. Future studies based on panic, anxiety, and depressive symptoms may elucidate PD associations with the internalizing spectrum of disorders.
doi:10.1016/j.jpsychires.2013.07.016
PMCID: PMC3881358  PMID: 23932575
DSM-IV personality disorders; DSM-IV substance use, mood, and anxiety disorders; epidemiology; structural equation modeling
16.  Mental Health of College Students and Their Non-college-attending Peers: Results from the National Epidemiologic Study on Alcohol and Related Conditions 
Archives of general psychiatry  2008;65(12):1429-1437.
Context
Although young adulthood is often characterized by rapid intellectual and social development, college-age individuals are also commonly exposed to circumstances that place them at risk for psychiatric disorders.
Objective
To assess 12-month prevalence of psychiatric disorders, sociodemographic correlates, and rates of treatment among individuals attending college and their non-college attending peers in the United States.
Design, Setting, Participants
Face-to-face interviews were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions ([NESARC] n=43,093). Analyses were done for the subsample of college-age individuals, defined as those aged 19-25 that were both attending (n=2,188) and not attending college (n=2,904) in the previous year.
Main Outcome Measure
Sociodemographic correlates and prevalence of 12-month DSM-IV psychiatric disorders, substance use, and treatment seeking among college-attending individuals and their non-college attending peers.
Results
Almost half of college-age individuals had a psychiatric disorder in the past year. The overall rate of psychiatric disorders was not different between college-attending individuals and their non-college attending peers. The unadjusted risk of alcohol use disorders was significantly greater for college students than their non-college attending peers (OR: 1.25, 95%, CI:1.04-1.50), though not after adjusting for background socio-demographic characteristics (AOR: 1.19, 95%: 0.98-1.44). College students were significantly less likely (unadjusted and adjusted) to have a diagnosis of drug use disorder or nicotine dependence or have used tobacco than their non-college-attending peers. Bipolar disorder was less common in individuals attending college. College students were significantly less likely to receive past year treatment for alcohol/drug use disorders than their non-college-attending peers.
Conclusions
Psychiatric disorders, particularly alcohol use disorders, are common in the college-age population. Although treatment rates varied across disorders, overall, less than 25% of individuals with a mental disorder sought treatment in the year prior to the survey. These findings underscore the importance of treatment and prevention interventions among college-age individuals.
doi:10.1001/archpsyc.65.12.1429
PMCID: PMC2734947  PMID: 19047530
17.  Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population 
The Journal of clinical psychiatry  2008;69(7):1112-1121.
Objective
This study sought to determine whether Black/White disparities in service utilization for mental health and substance use disorders persist or are diminished among individuals with psychiatric comorbidity in the general population.
Method
The 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) was used to identify individuals with lifetime co-occurring substance use disorders and mood/anxiety disorders (N=4,250; 3597 Whites and 653 Blacks). Lifetime service utilization for problems with mood, anxiety, alcohol and drugs was assessed.
Results
Compared to Whites, Blacks with co-occurring mood or anxiety and substance use disorders were significantly less likely to receive services for mood or anxiety disorders, equally likely to receive services for alcohol use disorders, and more likely to receive some types of services for drug use disorders. Regardless of race/ethnicity, individuals with these co-occurring disorders were almost twice as likely to use services for mood/anxiety disorders than for substance use disorders.
Conclusion
Despite the fact that comorbidity generally increases the likelihood of service use, Black/White disparities in service utilization among an all-comorbid sample were found, although these disparities differed by type of disorder. Further research is warranted to understand the factors underlying these differences. Prevention and intervention strategies are needed to address the specific mental health needs of Blacks with co-occurring disorders, as well as the overall lack of service use for substance use disorders among individuals with co-occurring psychiatric conditions.
PMCID: PMC2745048  PMID: 18517286
service utilization; race/ethnicity; comorbidity; mood/anxiety disorders; substance use disorders
18.  The Role of Alcohol Consumption in Future Classifications of Alcohol Use Disorders 
Drug and alcohol dependence  2007;89(1):82-92.
Background
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.
Methods
Data came from a large, nationally representative sample of the U.S. adult population.
Results
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.
Conclusion
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.
doi:10.1016/j.drugalcdep.2006.12.003
PMCID: PMC2727876  PMID: 17240085
Alcohol use disorder; IRT analysis; addiction; physical dependence; high-risk drinking patterns
19.  Psychiatric Disorders in Pregnant and Postpartum Women in the United States 
Archives of general psychiatry  2008;65(7):805-815.
CONTEXT
Psychiatric disorders and substance use during pregnancy are associated with adverse outcomes for mothers and their offspring. Information about the epidemiology of psychiatric disorders and substance use in this population is lacking.
OBJECTIVE
To examine sociodemographic correlates, rates of DSM-IV Axis I psychiatric disorders, substance use and treatment-seeking among past-year pregnant and postpartum women in the United States.
DESIGN, SETTING, AND PARTICIPANTS
Face-to-face interviews were conducted in the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093).
MAIN OUTCOME MEASURES
Prevalence of 12-month DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking.
RESULTS
There were no significant differences in the 12-month prevalence of psychiatric disorders between past-year pregnant (25.3%), postpartum women (27.5%), and non-pregnant women of child-bearing age (30.1%), except for the significantly higher prevalence of major depressive disorder in postpartum women (9.3%) than in non-pregnant women (8.1%) (OR 1.59, 95% CI=1.15–2.20). Past-year pregnant and postpartum women had significantly lower rates of alcohol use disorders, and any substance use, except illicit drug use, than non-pregnant women. Age, marital status, health status, stressful life events, and history of traumatic experiences were all significantly associated with higher risk of psychopathology in pregnant and postpartum women. Most women with a current psychiatric disorder did not receive any mental health care in the 12-months prior to the survey regardless of pregnancy status.
CONCLUSIONS
Pregnancy per se is not associated with increased risk of mental disorders, though the risk of major depressive disorder may be increased during the postpartum period. Young, unmarried women with recent stressful life events, complicated pregnancies, and poor overall health were at significantly increased risk of mental disorders during pregnancy. Low rates of maternal mental health care underscore the need to improve recognition and delivery of treatment for mental disorders occurring during pregnancy and the postpartum.
doi:10.1001/archpsyc.65.7.805
PMCID: PMC2669282  PMID: 18606953
20.  Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Narcissistic Personality Disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions 
The Journal of clinical psychiatry  2008;69(7):1033-1045.
Objectives
To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of narcissistic personality disorder (NPD) among men and women.
Methods
Face-to-face interviews with 34,653 adults participating in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions.
Results
Prevalence of lifetime NPD was 6.2%, with rates greater for men (7.7%) than women (4.8%). NPD was significantly more prevalent among Black men and women and Hispanic women, younger adults, and separated/divorced/widowed and never married adults. NPD was associated with mental disability among men but not women. High co-occurrence rates of substance use, mood, anxiety, and other personality disorders (PDs) were observed. With additional comorbidity controlled for, associations with bipolar I disorder, PTSD, and schizotypal and borderline PDs remained significant, but weakened, among men and women. Similar associations were observed between NPD and specific phobia, generalized anxiety disorder, and bipolar II disorder among women; and alcohol abuse, alcohol dependence, drug dependence, and histrionic and obsessive-compulsive PDs among men. Dysthymia was significantly and negatively associated with NPD.
Conclusions
NPD is a prevalent PD in the general U.S. population and is associated with considerable disability among men, whose rates exceed those of women. NPD may not be as stable as previously recognized or described in the DSM-IV. The results highlight the need for further research from numerous perspectives to identify the unique and common genetic and environmental factors underlying the disorder-specific associations with NPD observed in this study.
PMCID: PMC2669224  PMID: 18557663
21.  Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Borderline Personality Disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions 
Objectives
To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of BPD among men and women.
Methods
Face-to-face interviews with 34,653 adults participating in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions.
Results
Prevalence of lifetime BPD was 5.9% (99% CI: 5.4–6.4). There were no differences in the rates of BPD among men (5.6%, 99% CI: 5.0–6.2) and women (6.2%, 99% CI: 5.6–6.9). BPD was more prevalent among Native American men, younger and separated/divorced/widowed adults, and those with lower incomes and education, and less prevalent among Hispanic men and women and Asian women. BPD was associated with substantial mental and physical disability, especially among women. High co-occurrence rates of mood and anxiety disorders with BPD were similar. With additional comorbidity controlled, associations with bipolar disorder and schizotypal and narcissistic PDs remained strong and significant. Associations of BPD with other specific disorders were no longer significant or were considerably weakened.
Conclusions
Prevalence of BPD in the general population is much greater than previously recognized, equal prevalent among men and women, and associated with considerable mental and physical disability, especially among women. Unique and common factors may differentially contribute to disorder-specific comorbidity with BPD and some of these associations appear to be sex-specific. There is a need for future epidemiologic, clinical and genetically-informed studies to identify unique and common factors that underlie disorder-specific comorbidity with BPD. Important sex differences observed in rates of and associations with BPD can inform more focused, hypothesis-driven investigations of these factors.
PMCID: PMC2676679  PMID: 18426259
22.  Other- and Self-Directed Forms of Violence and Their Relationships to DSM-IV Substance Use and Other Psychiatric Disorders in a National Survey of Adults 
Comprehensive psychiatry  2013;54(7):731-739.
Objective
To examine associations between DSM-IV psychiatric disorders and other- and self- directed violence in the general population.
Methods
Data were obtained from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 & 2 (n=34,653). Four violence categories were derived from a latent class analysis (LCA) of 5 other-directed and 4 self-directed violent behavior indicators. Multinomial logistic regression examined class associations for gender, race-ethnicity, age and DSM-IV substance use, mood, anxiety, and personality disorders.
Results
Approximately 16% of adults reported some form of violent behavior distributed as follows: other-directed only, 4.6%; self-directed only, 9.3%; combined self- and other-directed, 2.0%; and no violence, 84.1%. The majority of the DSM-IV disorders included in this study were significantly and independently related to each form of violence. Generally, other-directed violence was more strongly associated with any substance use disorders (81%) and any personality disorders (42%), while self-directed violence was more strongly associated with mood (41%) and anxiety disorders (57%). Compared with these two forms of violence, the smaller group with combined self- and other-directed violence was more strongly associated with any substance use disorders (88%), mood disorders (63%), and personality disorders (76%).
Conclusion
Findings from this study are consistent with recent conceptualizations of disorders as reflecting externalizing disorders and internalizing disorders. The identification of the small category with combined forms of violence further extends numerous clinical studies which established associations between self- and other-directed violent behaviors. The extent to which the combined violence category represents a meaningful and reliable category of violence requires further detailed studies.
doi:10.1016/j.comppsych.2013.02.003
PMCID: PMC3779474  PMID: 23587529
23.  The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): Reliability of New Psychiatric Diagnostic Modules and Risk Factors in a General Population Sample 
Drug and alcohol dependence  2007;92(1-3):27-36.
This study presents test-retest reliability statistics and information on internal consistency for new diagnostic modules and risk factor of alcohol, drug, and psychiatric disorders the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV). Test-retest statistics were derived from a random sample of 1,899 adults selected from 34,653 respondents who participated in the 2004–2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Internal consistency of continuous scales was assessed using the entire Wave 2 NESARC. Both test and retest interviews were conducted face-to-face. Test-retest and internal consistency results for diagnoses and symptom scales associated with posttraumatic stress disorder, attention-deficit/hyperactivity disorder, and borderline, narcissistic, and schizotypal personality disorders were predominantly good (kappa > 0.63; ICC > 0.69; alpha > 0.75) and reliability for risk factor measures fell within the good to excellent range (intraclass correlations = 0.50–0.94; alpha = 0.64–0.90). The high degree of reliability found in this study suggests that new AUDADIS-IV diagnostic measures can be useful tools in research settings. The availability of highly reliable measures of risk factors of alcohol, drug, and psychiatric disorders will contribute to the validity of conclusions drawn from future research in the domains of substance use disorder and psychiatric epidemiology.
doi:10.1016/j.drugalcdep.2007.06.001
PMCID: PMC2246381  PMID: 17706375
Reliability; alcohol and drug use disorders; risk factors; test-retest reliability; general population; internal consistency
24.  Crosswalk between DSM-IV Dependence and DSM-5 Substance Use Disorders for Opioids, Cannabis, Cocaine and Alcohol 
Drug and alcohol dependence  2013;132(0):387-390.
Background
Ascertaining agreement between DSM-IV and DSM-5 is important to determine the applicability of treatments for DSM-IV conditions to persons diagnosed according to the proposed DSM-5.
Methods
Data from a nationally representative sample of US adults were used to compare concordance of past-year DSM-IV Opioid, Cannabis, Cocaine and Alcohol Dependence with past-year DSM-5 disorders at thresholds of 3+, 4+ 5+ and 6+ positive DSM-5 criteria among past-year users of opioids (n=264), cannabis (n=1,622), cocaine (n=271) and alcohol (n=23,013). Substance-specific 2×2 tables yielded overall concordance (kappa), sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV).
Results
For DSM-IV Alcohol, Cocaine and Opioid Dependence, optimal concordance occurred when 4+ DSM-5 criteria were endorsed, corresponding to the threshold for moderate DSM-5 Alcohol, Cocaine and Opioid Use Disorders. Maximal concordance of DSM-IV Cannabis Dependence and DSM-5 Cannabis Use Disorder occurred when 6+ criteria were endorsed, corresponding to the threshold for severe DSM-5 Cannabis Use Disorder. At these optimal thresholds, sensitivity, specificity, PPV and NPV generally exceeded 85% (>75% for cannabis).
Conclusions
Overall, excellent correspondence of DSM-IV Dependence with DSM-5 Substance Use Disorders was documented in this general population sample of alcohol, cannabis, cocaine and opioid users. Applicability of treatments tested for DSM-IV Dependence is supported by these results for those with a DSM-5 Alcohol, Cocaine or Opioid Use Disorder of at least moderate severity or Severe Cannabis Use Disorder. Further research is needed to provide evidence for applicability of treatments for persons with milder substance use disorders.
doi:10.1016/j.drugalcdep.2013.02.036
PMCID: PMC3748225  PMID: 23642316
DSM-IV; DSM-5; substance use disorder; concordance; kappa; diagnosis
25.  DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale 
The American journal of psychiatry  2013;170(8):834-851.
Since DSM-IV was published in 1994, its approach to substance use disorders has come under scrutiny. Strengths were identified (notably, reliability and validity of dependence), but concerns have also arisen. The DSM-5 Substance-Related Disorders Work Group considered these issues and recommended revisions for DSM-5. General concerns included whether to retain the division into two main disorders (dependence and abuse), whether substance use disorder criteria should be added or removed, and whether an appropriate substance use disorder severity indicator could be identified. Specific issues included possible addition of withdrawal syndromes for several substances, alignment of nicotine criteria with those for other substances, addition of biomarkers, and inclusion of nonsubstance, behavioral addictions.
This article presents the major issues and evidence considered by the work group, which included literature reviews and extensive new data analyses. The work group recommendations for DSM-5 revisions included combining abuse and dependence criteria into a single substance use disorder based on consistent findings from over 200,000 study participants, dropping legal problems and adding craving as criteria, adding cannabis and caffeine withdrawal syndromes, aligning tobacco use disorder criteria with other substance use disorders, and moving gambling disorders to the chapter formerly reserved for substance-related disorders. The proposed changes overcome many problems, while further studies will be needed to address issues for which less data were available.
doi:10.1176/appi.ajp.2013.12060782
PMCID: PMC3767415  PMID: 23903334

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