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Both Barrels:
The Devastating Comorbidity of Anxiety Disorders and Substance Abuse

(Released May 2012)

 
  by J. Erick Sinkhorn  

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  1. Anxiety, mood, and substance use disorders in United States African-American public housing residents

    Adam Simning, Edwin van Wijngaarden and Yeates Conwell.

    Social psychiatry and psychiatric epidemiology, Vol. 46, No. 10, Oct 2011, pp. 983-92.

    African-Americans experience considerable mental healthcare disparities in the United States, but little is known about sensitive subgroups within this population. To better understand healthcare disparities within African-Americans communities, we characterized anxiety, mood, and substance use disorder prevalence and associated service utilization among public and non-public housing residents. We used data from a nationally representative sample of African-Americans recruited as part of the National Survey of American Life. In public housing residents, the 12-month prevalence of anxiety disorders was 1.8 times higher than in non-public housing residents (P = 0.002), mood disorders was 1.4 times higher (P = 0.189), and substance use disorders was 2.2 times higher (P = 0.031). Public housing remained associated with mental illness after controlling for sociodemographics and chronic illness. Public and non-public housing residents did not differ significantly in mental healthcare utilization, but utilization was low with 16-30% of public housing residents with a 12-month disorder receiving mental health assistance. A relatively high proportion of African-American public housing residents suffered from psychiatric disorders, and few received mental healthcare assistance, indicating that further work is needed to enhance utilization.[PUBLICATION ABSTRACT]

  2. Co-morbid PTSD and suicidality in individuals with schizophrenia and substance and alcohol abuse

    Nicholas Tarrier and Alicia Picken.

    Social psychiatry and psychiatric epidemiology, Vol. 46, No. 11, Nov 2011, pp. 1079-86.

    Suicide risk is high in schizophrenic patients and is further elevated in dual diagnosis patients. Suicide behaviour is a continuum from ideation, plans to attempts. Exposure to traumatic stress and co-morbid PTSD is elevated in schizophrenic patients. Suicide behaviour is also common in non-psychotic PTSD patients. This study aimed to investigate the effect of trauma and co-morbid PTSD on suicide behaviour in dual diagnosis patients and whether co-morbid PTSD would further elevate suicide risk. This was a cross-sectional study in which suicide behaviour was compared in those with and without co-morbid PTSD in 110 patients suffering schizophrenia and alcohol and/or substance abuse. 100 (91%) reported at least one traumatic event with an average of 4.3 events. 31 (28%) patients met criteria for full PTSD. Current suicidal ideation was reported by 39 (35%) and 23 (21%) reported plans and ideation, 69 (63%) reported at least one previous suicide attempt. Suicide behaviour was significantly associated with an increasing number of traumatic events. Suicidality was significantly associated and elevated with co-morbid PTSD. Analysis indicated that the effect of trauma on suicide behaviour appeared to be mediated by hopelessness. Suicide behaviour was not associated with exposure to trauma per se but was associated with incremental exposure to traumatic experiences. Consistent with the study hypotheses, co-morbid PTSD further adds to the risk of suicide behaviour in an already vulnerable group.[PUBLICATION ABSTRACT]

  3. Linking "big" personality traits to anxiety, depressive, and substance use disorders: A meta-analysis

    Roman Kotov, Wakiza Gamez, Frank Schmidt and David Watson.

    Psychological bulletin, Vol. 136, No. 5, 2010, pp. 768-821.

    We performed a quantitative review of associations between the higher order personality traits in the Big Three and Big Five models (i.e., neuroticism, extraversion, disinhibition, conscientiousness, agreeableness, and openness) and specific depressive, anxiety, and substance use disorders (SUD) in adults. This approach resulted in 66 meta-analyses. The review included 175 studies published from 1980 to 2007, which yielded 851 effect sizes. For a given analysis, the number of studies ranged from three to 63 (total sample size ranged from 1,076 to 75,229). All diagnostic groups were high on neuroticism (mean Cohen's d = 1.65) and low on conscientiousness (mean d = −1.01). Many disorders also showed low extraversion, with the largest effect sizes for dysthymic disorder (d = −1.47) and social phobia (d = −1.31). Disinhibition was linked to only a few conditions, including SUD (d = 0.72). Finally, agreeableness and openness were largely unrelated to the analyzed diagnoses. Two conditions showed particularly distinct profiles: SUD, which was less related to neuroticism but more elevated on disinhibition and disagreeableness, and specific phobia, which displayed weaker links to all traits. Moderator analyses indicated that epidemiologic samples produced smaller effects than patient samples and that Eysenck's inventories showed weaker associations than NEO scales. In sum, we found that common mental disorders are strongly linked to personality and have similar trait profiles. Neuroticism was the strongest correlate across the board, but several other traits showed substantial effects independent of neuroticism. Greater attention to these constructs can significantly benefit psychopathology research and clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)(journal abstract)

  4. The Relationship Between Anxiety Disorders and Substance Use Among Adolescents in the Community: Specificity and Gender Differences

    Ping Wu, Renee D. Goodwin, Cordelia Fuller, et al.

    Journal of Youth and Adolescence, Vol. 39, No. 2, Feb 2010, pp. 177-188.

    Using a sample of 781 adolescents (ages 13-17, 52.8% male) from a community survey, this study examined gender differences in the co-occurrence of specific anxiety disorders with substance use in adolescents. The associations between anxiety disorders and substance use differed according to the particular anxiety disorders and forms of substance use being examined, as well as by gender. Social phobia was associated with cigarette smoking among boys only. For girls, social phobia appeared to be negatively associated with drug use. For the other anxiety disorders, the associations with substance use tended to be stronger among girls. These findings highlight the need to improve clinical recognition of the anxiety disorders and to improve treatment access for afflicted adolescents. Future studies based on longitudinal data could further elucidate the relationships among anxiety disorders, gender, and substance use. [PUBLICATION ABSTRACT]

  5. The Role of a Prescription in Anxiety Medication Use, Abuse, and Dependence

    Miriam C. Fenton MPH, Katherine M. Keyes PhD, Martins, Silvia S,MD, PhD and Deborah S. Hasin PhD.

    The American Journal of Psychiatry, Vol. 167, No. 10, Oct 2010, pp. 1247-53.

    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.

  6. Anxiety, Mood, and Substance Use Disorders in Parents of Children With Anxiety Disorders

    Alicia A. Hughes, Jami M. Furr, Erica D. Sood, Andrea J. Barmish and Philip C. Kendall.

    Child psychiatry and human development, Vol. 40, No. 3, Sep 2009, pp. 405-19.

    Examined the prevalence of anxiety, mood, and substance use disorders in the parents of anxiety disordered (AD) children relative to children with no psychological disorder (NPD). The specificity of relationships between child and parent anxiety disorders was also investigated. Results revealed higher prevalence rates of anxiety disorders in parents of AD children relative to NPD children. Specific child-mother relationships were found between child separation anxiety and panic disorder and maternal panic disorder, as were child and maternal social phobia, obsessive compulsive disorder, and specific phobias. Findings are discussed with reference to theory, clinical implications, and future research needs. [PUBLICATION ABSTRACT]

  7. Disparities in Use of Mental Health and Substance Abuse Services by Persons With Co-occurring Disorders

    Barbara E. Havassy PhD, Jennifer Alvidrez and Amy A. Mericle PhD.

    Psychiatric Services, Vol. 60, No. 2, Feb 2009, pp. 217-23.

    Objectives: Individuals with co-occurring mental and substance use disorders require psychiatric and substance abuse treatments. A critical question is whether these individuals are treated for both disorders. Methods: This study prospectively examined 24-month service utilization patterns of 224 persons with co-occurring disorders who were recruited from crisis residential programs in the mental health treatment system (N=106) and from crisis residential detoxification programs in the substance abuse treatment system (N=118) in San Francisco. Utilization data were collected from the billing-information systems of both treatment systems. Demographic and clinical data were obtained in interviews with participants. Data were analyzed for group differences with chi square tests and logistic, linear, and zero-truncated negative binomial regression. Results: After the analyses controlled for demographic and clinical factors, participants recruited from the substance abuse treatment system were less likely than those from the mental health treatment system to obtain any mental health services, mental health day treatment, transitional residential care, case management, and other outpatient services (p<.001 for all comparisons). They were more likely to obtain crisis residential detoxification (p=.003), had more days of drug residential treatment (p=.028), but received fewer hours of outpatient services (p=.012). Conclusions: There were disparities in patterns of service utilization, although there were no significant diagnostic differences between the two groups. These findings should be valuable in considering systems development and modification. Furthermore, they can contribute to research about factors that underlie results. Study replications should be conducted to assess the robustness of these findings in other locales. (Psychiatric Services 60:217-223, 2009)

  8. Prevalence of Mood, Anxiety, and Substance-Abuse Disorders for Older Americans in the National Comorbidity Survey-Replication

    Amber M. Gum PhD, Bellinda King-Kallimanis and Robert Kohn.

    The American Journal of Geriatric Psychiatry, Vol. 17, No. 9, Sep 2009, pp. 769-92.

    To identify age differences in the 12-month and lifetime comorbidity of depressive and anxiety disorders for adults (18-64 years) compared with older adults (65 years and older) in a nationally representative sample of community-dwelling adults in the United States. Cross-sectional epidemiologic study, using data from the National Comorbidity Survey-Replication public use dataset. Community-based epidemiologic survey. Representative national sample of community-dwelling adults in the United States. The World Health Organization Composite International Diagnostic Interview was used to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric disorders. More than half of respondents with a 12-month major depressive disorder (MDD) had a comorbid anxiety disorder or dysthymia (18-64 years = 60.6%; 65 years and older = 51.8%). High rates of MDD were also found for those with anxiety disorders across both age groups, highest in the 18-64 years group for generalized anxiety disorder (28.5%) and highest in the 65 years and older group for panic disorder (36.7%). Age group did not predict 12-month diagnosis of a comorbid anxiety disorder among those with a depressive disorder in multivariate logistic regression. Onset of anxiety disorders preceded onset of depressive disorders for most older adults (77.6%). Depressive and anxiety disorders frequently cooccurred in this representative sample of community-dwelling adults. Older adults experienced comorbidity to a similar extent as younger adults, suggesting high rates of comorbidity across the lifespan.

  9. 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

    B. F. Grant, R. B. Goldstein, S. P. Chou, et al.

    Molecular psychiatry, Vol. 14, No. 11, Nov 2009, pp. 1051-66.

    The objective of this study was to present nationally representative findings on sociodemographic and psychopathologic predictors of first incidence of Diagnostic and Statistical Manual of Mental Disorders, 4th edn (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 disorders 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.

  10. Substance use after residential treatment among individuals with co-occurring disorders: The role of anxiety/depressive symptoms and trauma exposure

    Virginia Gil-Rivas, JoAnn Prause and Christine E. Grella.

    Psychology of Addictive Behaviors, Vol. 23, No. 2, 2009, pp. 303-314.

    This longitudinal study examined the contribution of anxiety/depressive symptoms and lifetime and recent trauma exposure to substance use after residential substance abuse treatment among individuals with co-occurring disorders. Data were collected from adults at treatment entry and 6 and 12 months later. At treatment entry, nearly all participants reported lifetime trauma exposure, and over one third met criteria for posttraumatic stress disorder (PTSD). Over the follow-up, nearly one third of the participants were exposed to trauma. Lifetime trauma exposure and a diagnosis of PTSD at treatment entry were not associated with substance use over the follow-up. Trauma exposure and anxiety/depressive symptoms over the follow-up were associated with an increased likelihood of substance use. Gender did not moderate the association between trauma exposure and anxiety/depressive symptoms and substance use. These findings highlight the importance of monitoring for trauma exposure and symptoms of anxiety/depression to better target interventions and continuing care approaches to reduce the likelihood of posttreatment substance use in this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)(journal abstract)

  11. Assessment of generalized anxiety disorder diagnostic criteria in the National Comorbidity Survey and Virginia Adult Twin Study of Psychiatric and Substance Use Disorders

    Thomas S. Kubarych, Steven H. Aggen, John M. Hettema, Kenneth S. Kendler and Michael C. Neale.

    Psychological assessment, Vol. 20, No. 3, 2008, pp. 206-216.

    The authors investigated measurement properties of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, generalized anxiety disorder (GAD) criteria in the National Comorbidity Survey and the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders (VATSPSUD). The two studies used different widely used instruments. There were significant (p < .001) differences in measurement of GAD due to age, study, and age-study interaction on item thresholds and factor loadings of GAD, especially when different stem-probe structures of interviews were taken into account. Item thresholds were estimated to differ by as much as -.74 as a function of age and .40 as a function of study. Despite these differences, factor scores derived from symptom criteria strongly predicted categorical diagnostic outcomes based on symptom count. It is concluded that interview structure, especially the stem-probe format of structured interviews, and wording had significant effects on study findings; that future studies in psychiatric epidemiology should use common structured interviews as much as possible; and that factor scores can be used in conjunction with sum scores as cut points to retain the advantages of both dimensional and categorical classification. (PsycINFO Database Record (c) 2010 APA, all rights reserved)(journal abstract)

  12. The association between anxiety and alcohol versus cannabis abuse disorders among adolescents in primary care settings

    Nancy C. Low, Sok S. Lee, Jeffrey G. Johnson, Janet B. Williams and Emily S. Harris.

    Family practice, Vol. 25, No. 5, Oct 2008, pp. 321-7.

    Background. Both clinical and population-based studies show that anxiety disorders and substance misuse frequently co-occur in adults, whereas among adolescents, less examination of this association has been done. Adolescence is frequently the time of substance use initiation and its subsequent interaction with anxiety disorders has not been fully explored. It is unknown in adolescents whether anxiety is more related to alcohol abuse versus cannabis abuse. In addition, as depression has been implicated in adolescents with both anxiety and substance misuse, its role in the association should also be considered. Objective. To test the association between current anxiety with alcohol versus cannabis abuse disorders. Method. Cross-sectional, clinician-administered, structured assessment--using the Primary Care Evaluation of Mental Disorders--to evaluate anxiety, mood and substance abuse disorders among 632 adolescents recruited from primary care settings. Results. Results show a strong association between current anxiety and alcohol [odds ratio = 3.8; 95% confidence interval (CI) 1.2-11.8], but not cannabis (odds ratio = 1.4; 95% CI 0.4-4.7) abuse. Conclusion. This association in adolescents reflects the importance for increased awareness of anxiety symptoms and alcohol use patterns in primary care. The lack of association of anxiety with cannabis abuse in this group may reflect differences in cannabis' anxiolytic properties or that this young group has had less exposure thus far. Given adolescence is a time of especially rapid psychosocial, hormonal and brain development, primary care may provide an opportunity for further investigation and, potentially, early screening and intervention.

  13. Association of Mood, Anxiety, and Substance Use Disorders With Occupational Status and Disability in a Community Sample

    Nady el-Guebaly, Shawn Currie, Jeanne Williams, et al.

    Psychiatric Services, Vol. 58, No. 5, May 2007, pp. 659-67.

    OBJECTIVE: This study examined associations between mood disorders, anxiety disorders, substance dependence or harmful alcohol use, and occupational status and disability in a general population sample. METHODS: Data from the Canadian Community Health Survey Cycle 1.2-Mental Health and Well-Being (CCHS-1.2), a representative cross-sectional survey, were analyzed. The total sample was narrowed to individuals between the ages of 18 and 64 years, the age range most likely to be working. RESULTS: Of the 27,332 persons surveyed, 946 had a mood disorder only, 831 had an anxiety disorder only, 730 had substance dependence only, and 966 had more than one disorder. Twenty-three percent reported that during the previous week they were not at a job or were permanently unable to work (27% with mood disorder only, 30% with anxiety disorder only, and 20% with substance dependence only, and 34% with more than one disorder). In unadjusted analyses, mood and anxiety disorders were associated with absence from work during the week preceding the interview, whereas substance dependence was not. After adjustment for other variables using logistic regression, an association of substance dependence and work absence emerged. Each category of disorder was strongly associated with a greater likelihood of disability days or days spent in bed for mental health reasons. CONCLUSIONS: On a population level, mood and anxiety disorders and substance dependence were associated both with not working during the week preceding the interview as well as an increase in reported disability or bed days. The strength of association appears to be stronger for mood and anxiety disorders. [PUBLICATION ABSTRACT]

  14. Stress Sensitization and Adolescent Depressive Severity as a Function of Childhood Adversity: A Link to Anxiety Disorders

    Emmanuel P. Espejo, Constance L. Hammen, Nicole P. Connolly, Patricia A. Brennan, Jake M. Najman and William Bor.

    Journal of abnormal child psychology, Vol. 35, No. 2, Apr 2007, pp. 287-99.

    The goal of the present study was to determine whether exposure to adversity in childhood contributes to a differential threshold at which stressful life events provoke depressive reactions in adolescence. In addition, to address empirical and conceptual questions about stress effects, the moderating effect of anxiety disorder history was also explored. This examination was conducted in a sample of 816 children of depressed and nondepressed mothers, who were followed from birth to age 15. Information on adversities experienced in childhood was collected both from mothers during the first five years of their youth's life and from the youths themselves at age 15, and included information on the mother's relationship with her partner, maternal psychopathology, as well as youth-reported abuse. Results indicated that youths with both greater exposure to adversity in childhood and a history of an anxiety disorder displayed increased depressive severity following low levels of episodic stress compared to youths with only one or neither of these risk factors. The results are speculated to reflect the possibility that early anxiety disorders associated with exposure to adversity in childhood may be a marker of dysregulated stress responses, and may help to account for the comorbidity of depression and anxiety in some individuals. [PUBLICATION ABSTRACT]

  15. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys

    Philip S. Wang, Sergio Aguilar-Gaxiola, Jordi Alonso, Matthias C. Angermeyer and et al.

    The Lancet, Vol. 370, No. 9590, Sep 8-Sep 14, 2007, pp. 841-50.

    Mental disorders are major causes of disability worldwide, including in the low-income and middle-income countries least able to bear such burdens. We describe mental health care in 17 countries participating in the WHO world mental health (WMH) survey initiative and examine unmet needs for treatment. Face-to-face household surveys were undertaken with 84850 community adult respondents in low-income or middle-income (Colombia, Lebanon, Mexico, Nigeria, China, South Africa, Ukraine) and high-income countries (Belgium, France, Germany, Israel, Italy, Japan, Netherlands, New Zealand, Spain, USA). Prevalence and severity of mental disorders over 12 months, and mental health service use, were assessed with the WMH composite international diagnostic interview. Logistic regression analysis was used to study sociodemographic predictors of receiving any 12-month services. The number of respondents using any 12-month mental health services (57 [2%; Nigeria] to 1477 [18%; USA]) was generally lower in developing than in developed countries, and the proportion receiving services tended to correspond to countries' percentages of gross domestic product spent on health care. Although seriousness of disorder was related to service use, only five (11%; China) to 46 (61%; Belgium) of patients with severe disorders received any care in the previous year. General medical sectors were the largest sources of mental health services. For respondents initiating treatments, 152 (70%; Germany) to 129 (95%; Italy) received any follow-up care, and one (10%; Nigeria) to 113 (42%; France) received treatments meeting minimum standards for adequacy. Patients who were male, married, less-educated, and at the extremes of age or income were treated less. Unmet needs for mental health treatment are pervasive and especially concerning in less-developed countries. Alleviation of these unmet needs will require expansion and optimum allocation of treatment resources.

  16. Antisocial Personality Disorder in Turkish Substance Dependent Patients and its Relationship with Anxiety, Depression and a History of Childhood Abuse

    Cuneyt Evren, Sevil Kural and Murat Erkiran.

    The Israel journal of psychiatry and related sciences, Vol. 43, No. 1, 2006, pp. 40-6.

    The prevalence of antisocial personality disorder (ASPD) in treatment-seeking Turkish substance dependent patients and the relationship of ASPD with clinical characteristics were studied. Participants were 132 inpatients with substance dependence according to the Structured Clinical Interview for DSM-IV (SCID-I), Turkish version. The clinician applied a semi-structured socio-demographic form, SCID-I, SCID-II, Childhood Abuse and Neglect Questionnaire (CANQ), Michigan Alcoholism Screening Test (MAST), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Among the 132 substance dependent patients, 31 (23.5%) had ASPD diagnosis and 56 (42.4%) had no personality disorder or personality traits. Rate of childhood physical abuse, childhood verbal abuse, childhood neglect, suicide attempt history, self-destructive behavior and lifetime major depression were higher among patients with ASPD. Also mean scores of BDI, BAI and MAST were higher among patients with ASPD. The high rate of ASPD found among Turkish substance dependent patients suggests that special attention must be paid to identify ASPD in this group. Findings in this study showed that there is an association between ASPD and childhood abuse, lifetime major depression and severity of substance use.

  17. CO-OCCURRENCE OF PERSONALITY DISORDERS WITH MOOD, ANXIETY, AND SUBSTANCE USE DISORDERS IN A YOUNG ADULT POPULATION

    Liisa Kantojärvi, Juha Veijola, Kristian Läksy, Jari Jokelainen and et al.

    Journal of personality disorders, Vol. 20, No. 1, Feb 2006, pp. 102-12.

    The purpose of this study was to determine the co-occurrence of DSM-III-R personality disorders (PDs) with mood, anxiety, and substance use disorders in a young adult population. The members of the Northern Finland 1966 Birth Cohort Project, living in the city of Oulu with an age of 31 years (N = 1,609) were invited to participate in a two-phase field study. The SCID I and II were used as diagnostic instruments. One hundred and seventy-seven out of 321 interviewed subjects met the criteria for mood, anxiety, or substance use disorders. Altogether 72 (41%) of the subjects with an Axis I disorder met the criteria for at least one PD. The weighted co-occurrence rate of any PD varied from 28% for mood disorders to 47% for anxiety disorders. PDs, especially those in Cluster C, are highly associated with Axis I psychiatric disorders in population. [PUBLICATION ABSTRACT]

  18. Diagnosis of Comorbid Psychiatric Disorders in Substance Users Assessed With the Psychiatric Research Interview for Substance and Mental Disorders for DSM-IV

    Deborah Hasin, Sharon Samet, Edward Nunes, Jakob Meydan and et al.

    The American Journal of Psychiatry, Vol. 163, No. 4, Apr 2006, pp. 689-96.

    The authors used the Psychiatric Research Interview for Substance and Mental Disorders for DSM-IV (PRISM-IV) to test the reliability of DSM-IV-defined disorders, including primary and substance-induced disorders, in substance-abusing subjects. Substance-abusing patients (N=285) from substance abuse/dual-diagnosis treatment settings and mental health treatment settings participated in test and blind retest interviews with the PRISM-IV, which includes specific guidelines for assessment of substance abusers. Kappas for primary and substance-induced major depressive disorder ranged from 0.66 to 0.75. Reliability for psychotic disorders, eating disorders, anti social personality disorder, and borderline personality disorder was in the same range. Reliability for most anxiety disorders was lower. Reliability was good to excellent (kappas ≥0.65) for most substance dependence disorders. Continuous measures (severity, age at onset) had intraclass correlation coefficients >0.70 with few exceptions. Reliability was better for primary than for substance-induced disorders, although not greatly so. Most DSM-IV psychiatric disorders can be assessed in substance-abusing subjects with acceptable to excellent reliability by using specifically designed procedures. Good reliability improves the likelihood of significant study results.

  19. Substance Abuse With Mental Disorders: Specialized Public Systems And Integrated Care

    M. Audrey Burnam and Katherine E. Watkins.

    Health affairs, Vol. 25, No. 3, May/Jun 2006, pp. 648-58.

    Separate public financing and regulation of substance (SA) abuse treatment distinct from mental health (MH) treatment preserves a focus on the special needs of those with substance abuse but creates challenges to providing appropriate care for the large number of people with co-occurring conditions. This paper reviews recent efforts to overcome these challenges through clinical and systems approaches that better integrate care. Although much progress has been made for some subgroups of people with co-occurring disorders, further efforts to develop and sustain clinically integrated service delivery approaches within separate systems, particularly in SA treatment settings, are needed. [PUBLICATION ABSTRACT]

  20. Use of Mental Health Care and Substance Abuse Treatment Among Adults With Co-occurring Disorders

    Katherine M. Harris and Mark J. Edlund.

    Psychiatric Services, Vol. 56, No. 8, Aug 2005, pp. 954-9.

    Objectives: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. Methods: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. Results: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use disorder with one or more mental health symptoms and without serious mental illness, 1,872 had a substance use disorder with serious mental illness, 13,759 had one or more mental health symptoms only, and 7,530 had a serious mental illness only. A substantial proportion of adults with comorbid mental health problems and a substance use disorder did not receive any treatment (46 percent of those with serious mental illness and 65 percent of those with one or more mental health symptoms). Co-occurring substance use disorder was not associated with increased use of mental health care. The likelihood of receiving any substance abuse treatment increased with the presence and severity of mental health problems. Across all five groups, use of mental health care was more common than use of substance abuse treatment. Less than one-third of patients with comorbid mental health problems and a substance use disorder who used mental health care also received substance abuse treatment. Conclusions: The large proportion of untreated individuals with mental and substance use disorders reinforces existing concerns about barriers to beneficial treatment. Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted. (Psychiatric Services 56:954-959, 2005)

  21. Co-Occurring Disorders in the Adolescent Mental Health and Substance Abuse Treatment Systems[dagger]

    Win C. Turner, Randolph D. Muck, Rebekah J. Muck, Robert L. Stephens and Bhuvana Sukumar.

    Journal of psychoactive drugs, Vol. 36, No. 4, Dec 2004, pp. 455-62.

    This article explores the rates of co-occurring disorders in two large federally-funded programs that target youth. In the mental health treatment system, the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) supports the Comprehensive Community Mental Health Services for Children and Their Families Program. SAMHSA's Center for Substance Abuse Treatment (CSAT) supports a number of grant programs providing substance abuse treatment for adolescents. The data from these programs underscores the need for the use of systematic, validated, biopsychosocial assessment instruments for all youth entering either the substance abuse or mental health treatment systems. The current evidence base for models of co-occurring treatment for youth is discussed and recommendations made for future activity related to adolescent co-occurring treatment.

  22. Promising Treatments for Women With Comorbid PTSD and Substance Use Disorders

    Denise A. Hien, Lisa R. Cohen, Gloria M. Miele, Lisa Caren Litt and Carrie Capstick.

    The American Journal of Psychiatry, Vol. 161, No. 8, Aug 2004, pp. 1426-32.

    Hien et al compare the efficacy of a manualized cognitive behavior therapy that addresses both posttraumatic stress disorder (PTSD) and substance abuse (seeking safety) with a manualized cognitive behavior therapy that addresses only substance abuse (relapse prevention) and with standard community care for the treatment of comorbid PTSD and substance abuse disorder. Seeking safety and relapse prevention are efficacious short-term treatments for low-income urban women with PTSD, substance use disorder, and other psychiatric symptoms.

  23. The effects of anxiety, substance use and conduct disorders on risk of major depressive disorder

    J. M. HETTEMA, C. A. PRESCOTT and K. S. KENDLER.

    Psychological medicine, Vol. 33, No. 8, Nov 2003, pp. 1423-32.

    Background. Major depressive disorder (MDD) is highly co-morbid with other Axis I disorders, which commonly precede its onset. We sought to determine the level and periods of risk for MDD posed by prior or co-occurring psychiatric disorders. Method. Using retrospective data from a longitudinal, population-based sample of 2926 male and 1929 female adult twin subjects, we predicted the hazard rates for MDD from a Cox proportional hazards model with same-year or prior onsets of co-morbid Axis I disorders as time-dependent covariates. Results. All axis I disorders studied (generalized anxiety disorder, panic disorder, phobia, alcohol dependence, psychoactive substance use disorders and conduct disorder) significantly predicted increased risk for developing MDD. The highest hazard rates occurred for MDD onsets that co-occurred with those of the co-morbid disorder. However, the risk for onset of MDD subsequent to that of prior disorders is also significantly increased and remains relatively unchanged over time. Although the risk for onset of MDD is significantly higher in women than men, this was not explained by gender differences in prior disorder prevalence or increased sensitivity in women to the effects of prior disorders on risk for depression. Conclusions. Prior psychiatric disorders are significant risk factors for the development of MDD, independent of the length of the intervening period between the onset of the first disorder and that of MDD. [PUBLICATION ABSTRACT]

  24. Temporal sequencing of lifetime mood disorders in relation to comorbid anxiety and substance use disorders

    R. de Graaf, R. V. Bijl, J. Spijker, A. T. F. Beekman and W. A. M. Vollebergh.

    Social psychiatry and psychiatric epidemiology, Vol. 38, No. 1, Jan 2003, pp. 1-11.

    Background: Little is known about the temporal sequencing of psychiatric disorders. The aim of this study was to obtain insight into patterns of co-occurrence of DSM-III-R mood disorders in relation to anxiety and substance use disorders, their temporal sequencing and the sociodemographic and long-term vulnerability predictors of this temporal sequencing. Methods: Data are from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a psychiatric epidemiological study in a representative sample of 7,076 adults aged 18-64. Results: Of those who had ever experienced a mood disorder, 46 % of males and 57 % of females had a history of anxiety disorders, and 43 % and 15 % of substance use disorders. Mood disorders were associated with all anxiety and substance use disorders, except with alcohol abuse among males. In the majority of anxiety-comorbid cases, the mood disorder arose after the anxiety disorder; the pattern for substance use-comorbid disorders was more variable. Deviation from the usual sequence of major depression and anxiety disorders was more often seen among females, subjects with a higher educational level, subjects who experienced childhood parental divorce, and subjects who experienced childhood emotional neglect. Conclusions: When comorbid with anxiety disorders, mood disorders clearly tend to be secondary. Few of the studied demographic factors, familial vulnerability factors and childhood life events predict the sequencing of mood disorders in relation to other disorders.

  25. Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents

    Dean G. Kilpatrick, Kenneth J. Ruggiero, Ron Acierno, Benjamin E. Saunders, Heidi S. Resnick and Connie L. Best.

    Journal of consulting and clinical psychology, Vol. 71, No. 4, 2003, pp. 692-700.

    With a national household probability sample of 4,023 telephone-interviewed adolescents ages 12-17, this study provides prevalence, comorbidity, and risk-factor data for posttraumatic stress disorder (PTSD), major depressive episode (MDE), and substance abuse/dependence (SA/D). Roughly 16% of boys and 19% of girls met criteria for at least 1 diagnosis. Six-month PTSD prevalence was 3.7% for boys and 6.3% for girls, 6-month MDE prevalence was 7.4% for boys and 13.9% for girls. and 12-month SAM prevalence was 8.2% for boys and 6.2% for girls. PTSD was more likely to be comorbid than were MDE and SA/D. Results generally support the hypothesis that exposure to interpersonal violence (i.e., physical assault, sexual assault, or witnessed violence) increases the risk of these disorders and of diagnostic comorbidity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)(journal abstract)

  26. Anxiety Sensitivity and the Situational Antecedents to Drug and Alcohol Use: An Evaluation of Anxiety Patients with Substance Use Disorders

    Ryan A. B. DeHaas, John E. Calamari and John P. Bair.

    Cognitive Therapy and Research, Vol. 26, No. 3, Jun 2002, pp. 335-353.

    Although anxiety and substance use disorders co-occur at a high rate, little is known about the cause of this association. Relations between anxiety sensitivity (AS), posited to play an important role in the development of anxiety disorders and some substance use problems, the situational antecedents of drug and alcohol use, and substance preference, were evaluated in inpatients with anxiety or mood disorders and concurrent substance use disorders. AS predicted substance use even after controlling for variance attributable to trait anxiety and diagnostic status. AS was more strongly associated with the use of depressants in situations involving negative reinforcement. If AS proves to be a reliable risk factor for anxiety disorders co-occurring with substance use disorders, interventions structured to reduce AS would become important components of treatment and prevention programs.

  27. Risk factors for 12-month comorbidity of mood, anxiety, and substance use disorders: Findings from the Netherlands Mental Health Survey and Incidence Study

    Ron de Graaf, Rob V. Bijl, Filip Smit, Wilma A. M. Vollebergh and J. Spijker.

    The American Journal of Psychiatry, Vol. 159, No. 4, Apr 2002, pp. 620-9.

    The results of the Netherlands Mental Health Survey and Incidence Study show that high levels of psychiatric comorbidity exist in the general population. The risk factor profiles for comorbid disorders differ considerably from those for pure disorders.

  28. Brief screening for psychological and substance abuse disorders in veterans with long-term spinal cord injury

    Kenneth R. Weingardt, Jeanette Hsu and Michael E. Dunn.

    Rehabilitation Psychology, Vol. 46, No. 3, 2001, pp. 271-278.

    Objective: To determine rates of positive screens for psychological and substance use disorders in persons with long-term spinal cord injury (SCI). Study Design: A naturalistic cohort design wherein consecutive admissions during an 8-month period completed the screening battery. Setting: Veterans Affairs SCI Center. Participants: One hundred fifteen men, 2 women, mean age 57.4 years, injured an average of 20 years, readmitted for various reasons. Main Outcome Measures: The Alcohol Use Disorders Identification Test (AUDIT) and screening items for depression and anxiety disorders. Results: Rates of positive screens ranged from 6.2% for alcohol problems to over 40% for anxiety disorders. Positive screens for depression and anxiety correlated positively with the number of recent hospital admissions. Conclusions: Systematic brief screening for psychological and substance abuse disorders in this population revealed rates of positive screens at least equal to those in other medical patient populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)(journal abstract)

  29. Familial psychiatric illness and posttraumatic stress disorder: Findings from a family study of substance abuse and anxiety disorders

    Lisa C. Dierker and Kathleen R. Merikangas.

    The Journal of clinical psychiatry, Vol. 62, No. 9, Sep 2001, pp. 715-20.

    BACKGROUND: Aside from the possibility of a direct relationship between individual and familial posttraumatic stress disorder (PTSD), there is accumulating evidence that implicates a family history of psychiatric and substance use disorders as an important risk factor in the development of PTSD and associated symptoms. METHOD: The familial risk of DSM-III-R PTSD was examined within a family study of clinical- and community-ascertained probands (N = 263) and their 1206 adult first-degree relatives. RESULTS: Although PTSD among probands was not found to significantly elevate the risk of PTSD among first-degree relatives, an elevated rate of PTSD was found among the relatives of drug abusing probands compared with the relatives of probands with alcoholism, other anxiety disorders, and normal controls. Additionally, affective disorders were significantly associated with PTSD in relatives (p < .01). When these familial and individual associations were examined according to gender, drug disorders in probands were significantly associated with PTSD only among male relatives (p < .01), while the association between PTSD and comorbid affective disorders was seen primarily among female relatives (p < .01). CONCLUSION: Although probands in the present family study were not selected specifically for PTSD, the data afforded a unique opportunity to examine the profile of familial psychopathology as a part of the complex picture of susceptibility for PTSD. Future family study research will be able to determine the generalizability of the present findings through more complete measurement of diverse forms of trauma.

  30. The long-term treatment outcomes of depression and anxiety comorbid with substance abuse

    Gregory Bovasso.

    The Journal of Behavioral Health Services & Research, Vol. 28, No. 1, Feb 2001, pp. 42-57.

    The impact of the comorbidity of psychiatric disorder and substance abuse on treatment outcomes in the general population was estimated using data from a longitudinal survey of 1,920 individuals who were randomly sampled and followed over a nearly 15 year period. Individuals with anxiety or depression symptoms at baseline generally experienced increased distress at follow-up, but those with symptoms who received mental health treatment experienced decreased distress at follow up. The results may improve the understanding of the degree to which treatment of a primary disorder may be expected to prevent the incidence, or reduce the prevalence of a secondary, comorbid disorder.

  31. A longitudinal study of children of alcoholics: Predicting young adult substance use disorders, anxiety, and depression

    Laurie Chassin, Steven C. Pitts, Christian DeLucia and Michael Todd.

    The Journal of Abnormal Psychology, Vol. 108, No. 1, 1999, pp. 106-119.

    This study tested the specificity of parent alcoholism effects on young adult alcohol and drug abuse/dependence, anxiety, and depression, and tested whether adolescent symptomatology and substance use mediated parent alcoholism effects. Participants were from a longitudinal study in which a target child was assessed in adolescence and young adulthood with structured interview measures (N = 454 families at Time 1). Results showed unique effects of parent alcoholism on young adult substance abuse/dependence diagnoses over and above the effects of other parental psychopathology. There was some evidence of parent alcoholism effects on young adult depression and of maternal alcoholism effects on young adult anxiety, although these were not found consistently across subsamples. Mediational models suggested that parent alcoholism effects could be partially (but not totally) explained by adolescent externalizing symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)(journal abstract)

  32. Substance abuse patients with posttraumatic stress disorder (PTSD): Identifying specific triggers of substance use and their associations with PTSD symptoms

    Erica J. Sharkansky, Deborah J. Brief, Jessica M. Peirce, Jeffrey C. Meehan and Laura M. Mannix.

    Psychology of Addictive Behaviors, Vol. 13, No. 2, 1999, pp. 89-97.

    Although individuals with comorbid posttraumatic stress disorder (PTSD) and substance use diagnoses are at heightened risk for relapse after substance abuse treatment, little is known about the specific situations in which these individuals are likely to relapse. The present study was designed to test whether a PTSD diagnosis related to substance use in specific situations in which PTSD symptoms were likely to be present. Data were gathered from inpatients (n = 86) in a substance-abuse treatment program, and relationships between PTSD diagnosis and frequency of substance use in high-risk situations were examined. As predicted, PTSD diagnosis was related to substance use in situations involving unpleasant emotions, physical discomfort, and interpersonal conflict, but not to substance use in other situations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)(journal abstract)

  33. Comorbid Substance Use and Anxiety Disorders in Adolescents

    Deborah Deas-nesmith, Kathleen T. Brady and Sallie Campbell.

    Journal of Psychopathology and Behavioral Assessment, Vol. 20, No. 2, Jun 1998, pp. 139-148.

    To explore the coexistence of substance use disorders and anxiety disorders in adolescents, we assessed adolescents presenting for treatment to an inpatient substance abuse treatment facility (SUH), an inpatient psychiatric treatment facility (IPH), and a community-based psychiatric facility (CMHC) for comorbid substance use and psychiatric diagnoses. Thirty subjects from each facility (N=90) were interviewed using the revised Child Schedule for Affective Disorders and Schizophrenia (K-SADS) and the Structured Clinical Interview DSM-III-R (SCID-R) for substance use diagnoses. Overall, comorbidity (anxiety and substance use disorders) prevalence was 67% (20/30) of adolescents in the SUH group, 33% (10/30) of the CMHC adolescents, and 33% (10/30) of the IPH adolescents. Alcohol and marijuana were the most frequently abused substances. Anxiety disorders commonly coexist with substance use disorders in adolescents. Early identification and treatment of anxiety disorders may in fact prevent substance abuse in this population. [PUBLICATION ABSTRACT]

  34. Chronic PTSD in Vietnam combat veterans: Course of illness and substance abuse

    J. Douglas Bremner, Steven M. Southwick, Adam Darnell and Dennis S. Charney.

    The American Journal of Psychiatry, Vol. 153, No. 3, Mar 1996, pp. 369-75.

    The purpose of this study was to measure the longitudinal course of specific symptoms of posttraumatic stress disorder (PTSD) and related symptoms of alcohol and substance abuse and the effects of alcohol and substances on the symptoms of PTSD. A structured interview for the assessment of PTSD and alcohol and substance abuse, as well as other factors such as life stressors and treatment, was administered to 61 Vietnam combat veterans with PTSD. Onset of symptoms typically occurred at the time of exposure to combat trauma in Vietnam and increased rapidly during the first few years after the war. Symptoms plateaued within a few years after the war, following which the disorder became chronic and unremitting. Hyperarousal symptoms such as feeling on guard and feeling easily startled developed first, followed by avoidant symptoms and finally by symptoms from the intrusive cluster. The onset of alcohol and substance abuse typically was associated with the onset of symptoms of PTSD, and the increase in use paralleled the increase of symptoms. Patients reported a tendency for alcohol, marijuana, heroin, and benzodiazepines to make PTSD symptoms better, while cocaine made symptoms in the hyperarousal category worse. There was no relationship between treatment interventions and the natural course of PTSD. These findings suggest that symptoms of PTSD begin soon after exposure to trauma, that hyperarousal symptoms are the first symptoms to occur, that the natural course of alcohol and substance abuse parallels that of PTSD, and that specific substances have specific effects on PTSD symptoms.

  35. Clinical study of the relation of borderline personality disorder to Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders

    James J. Hudziak, Todd J. Boffeli, Jerald J. Kriesman, Marco M. Battaglia and et al.

    The American Journal of Psychiatry, Vol. 153, No. 12, Dec 1996, pp. 1598-606.

    The criteria for borderline personality disorder seem to select patients with very high rates of Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders. This study was undertaken to determine whether systematic assessment of patients with borderline personality disorder would reveal characteristic features of that condition which would distinguish it from these other disorders. Eighty-seven white female patients (75 in St. Louis and 12 in Milan, Italy) who had borderline personality disorder according to both the DSM-III-R criteria and the Revised Diagnostic Interview for Borderlines were further examined with the DSM-III-R Checklist and the Perley-Guze Hysteria Checklist to determine their patterns of psychiatric comorbidity. Every patient had at least one additional DSM diagnosis. Patients in St. Louis and Milan averaged five and four additional diagnoses, respectively. Eighty-four percent of the patients in St. Louis met criteria for either somatization disorder, Briquet's syndrome, antisocial personality disorder, or substance abuse disorders. Patterns of comorbidity for panic (51%), generalized anxiety disorder (55%), and major depression (87%) in St. Louis were consistent with those in other studies. The data indicate that the boundaries for the borderline condition are not specific and identify a high percentage of patients with these other disorders. Furthermore, the comorbidity profiles closely resemble the psychiatric profiles of patients with these disorders. If the borderline syndrome is meant to include all of these disorders, its usefulness as a diagnosis is limited. Until the fundamental features of borderline personality disorder that distinguish it from the others are identified, it is recommended that clinicians carefully assess patients for these other diagnoses. Efforts should be made to change the borderline personality disorder criteria by shifting away from overlap with the criteria for the other disorders.

  36. Co-occurrence of substance abuse with conduct, anxiety, and depression disorders in juvenile delinquents

    Bryan Neighbors, Tracy Kempton and Rex Forehand.

    Addictive Behaviors, Vol. 17, No. 4, 1992, pp. 379-386.

    Examined the co-occurrence of substance abuse and 3 other psychiatric disorders (conduct disorder, depression, anxiety) in 111 juvenile delinquents. Diagnostic interviews were utilized to place Ss in 1 of 3 groups: No substance abuse, alcohol/marijuana abuse, or polysubstance abuse. Frequency of diagnosis and number of symptoms of 3 psychiatric disorders were then examined. Results indicate that the diagnosis of conduct disorder increased significantly with the occurrence of substance abuse. Also, the number of symptoms for conduct disorder, anxiety, and depression increased with substance abuse. With polysubstance abuse the probability of having more than one of the other psychiatric diagnoses was above 50%. Potential explanations for the findings, focusing on the developmental trajectory for conduct problems and self-medication for internalizing disorders, are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)