Test-Retest Reliability of the Computerized CIDI (CIDI-Auto): Substance Abuse Modules

ICD-11/DSM-5: Entwicklungen und Änderungen bei Alkohol- und Substanzbezogenen Störungen

Die derzeitig gültigen ICD-10 Kriterien für alkohol- und substanzbezogene Abhängigkeit und schädlichen Gebrauch sind seit 1994 gültig. Ziel dieses Reviews ist es, die psychometrischen Eigenschaften Reliabilität der ICD-10 Diagnosen sowie einzelner Diagnosekriterien zu zeigen und ihre Konvergenz mit DSM-IV Diagnosen abzugleichen. Darüber hinaus werden die Hintergründe für die Entwicklung von ICD-11 und DSM-5 präsentiert und die Konvergenz zwischen diesen Diagnosesystemen (DSM-IV/5 mit ICD-10/11) berichtet. Die Vor- und Nachteile der Entwicklung von ICD- und DSM-Konzepten und deren Konvergenz werden kritisch diskutiert.

Affective and Sensation-Seeking Pathways Linking Borderline Personality Disorder Symptoms and Alcohol-Related Problems in Young Women

Borderline personality disorder (BPD) and alcohol use disorder often cooccur, yet we know little about risk processes underlying this association. We tested two mechanistic pathways linking BPD symptoms and alcohol-related problems. In the "affective pathway," we hypothesized that BPD symptoms would be associated with alcohol-related problems through affective instability and drinking to cope. In the "sensation-seeking pathway," we proposed that BPD symptoms would be related to alcohol-related problems through sensation seeking and drinking to enhance positive experiences. We tested a multiple mediation model using age-18 cross-sectional data from the Pittsburgh Girls Study. Results supported both pathways: BPD symptoms had an indirect effect on alcohol-related problems by (1) affective instability and coping motives (β = .03, p < .05), and (2) sensation-seeking and enhancement motives (β = .02, p < .05). These results highlight coping and enhancement drinking motives as possible mechanisms that explain co-occurrence of BPD symptoms and alcohol-related problems in young females.

Welfare stigma as a risk factor for major depressive disorder: Evidence from the Supplemental Nutrition Assistance Program

BACKGROUND

Negative public attitude about welfare is known to impair feelings of self-worth and psychological well-being in welfare recipients. What is missing in the extant literature is whether the stress of being on welfare increases the risk for clinically severe depression. To fill this gap, the present study examines the association between participation in the food stamp program and major depressive disorder.

METHODS

Study data is drawn from the 2008-2014 waves of the Health and Retirement Study (N = 67076). Depressive symptom is assessed with the Composite International Diagnostic Interview - Short Form, and modeled by a continuous score of major depressive symptoms (0-7) and a binary indicator for three or more symptoms. A fixed effects regression is used to estimate changes in depressive symptoms explained by the food stamp participation, adjusted for confounding covariates.

RESULTS

Food stamp participation was associated with an average of 19% increases in depressive symptoms (p < 0.001) and 29% higher odds of having major depression (p < 0.01). The associations were statistically significant only for men, middle-aged adults, Whites, and those without disability - groups that are more likely to be stigmatized by the social norm for not being able to rise above poverty.

LIMITATIONS

Depression outcomes are self-reported. Causality remains not established. The recession during the study periods may have dampened the stigma effects.

CONCLUSIONS

Welfare participation is a risk factor for clinical depression in a low-income setting. Depressive symptoms induced by welfare stigma need to be clinically targeted through counseling and cognitive therapy programs.

Associations between personality disorders and cannabis use and cannabis use disorder: a population-based twin study

BACKGROUND AND AIMS

Individual differences in DSM-IV personality disorders (PDs) are associated with increased prevalence of substance use disorders. Our aims were to determine which combination of PDs trait scores best predict cannabis use (CU) and cannabis use disorder (CUD), and to estimate the size and significance of genetic and environmental risks in PD traits shared with CU and CUD.

DESIGN

Linear mixed-effects models were used to identify PD traits for inclusion in twin analyses to explore the genetic and environmental associations between the traits and cannabis use.

SETTING

Cross-sectional data were obtained from Norwegian adult twins in a face-to-face interview in 1999-2004 as part of a population-based study of mental health.

PARTICIPANTS

Subjects were 1419 twins (μage  = 28.2 years, range = 19-36) from the Norwegian Institute of Public Health Twin Panel with complete PD and cannabis data.

MEASUREMENTS

PD traits were assessed using DSM-IV criteria. Life-time CU and CUD were based on DSM-IV abuse and dependence criteria, including withdrawal and craving.

FINDINGS

After adjusting for age and sex, antisocial [β = 0.23, 95% confidence interval (CI) = 0.19-0.28] and borderline PDs (β = 0.20, 95% CI = 0.14-0.26) were associated strongly with CU. Antisocial (β = 0.26, 95% CI = 0.21-0.31) and borderline PDs (β = 0.12, 95% CI = 0.06-0.18) were also linked strongly to CUD. Genetic risks in antisocial and borderline PD traits explained 32-60% of the total variance in CU and CUD. Dependent and avoidant PDs explained 11 and 16% of the total variance in CU and CUD, respectively.

CONCLUSIONS

Individual differences in the liability to cannabis use and cannabis use disorder appear to be linked to genetic risks correlated with antisocial and borderline personality disorder traits.

Sex differences in traumatic events and psychiatric morbidity associated to probable posttraumatic stress disorder among Latino prisoners

Latinos comprised 17.1% of the U.S. population and 33.1% of US prisoners, yet they are underrepresented in the psychopathology literature. Despite higher rates of trauma among incarcerated individuals than in the general population, most of the previous research in this area focused primarily on women samples, and very few studies examined sex differences in PTSD and traumatic experiences. In addition, there is a need for research assessing traumatic experiences and probable PTSD in men and women Latino inmates to inform culturally competent care and sex sensitive care for this vulnerable and underserved population. Our study examined whether men and women Latino inmates with probable Posttraumatic Stress Disorder (PTSD), based on the cut off 40 or more symptoms on the Davidson Trauma Scale (DTS), differed significantly by the number of event types experienced, the type of potentially traumatizing event, and in co-occurring psychiatric conditions. A multi-stage sample design was used to select a probabilistic sample of 1,331 inmates from 26 penal institutions in PR of which 1179 participated in the study. Bivariate associations were calculated for each type of traumatic event and probable PTSD. Mean number of types of potentially traumatizing event experienced was comparable for both sexes (F = 3.83, M = 3.74) yet sex differences were found in the nature of the event. Women with probable PTSD had higher rates of experiencing rape and sexual abuse. Men had higher rates of experiencing combat in war, a life-threatening accident, of witnessing violence, and being threatened with a weapon. Men with significant ADHD symptoms in childhood and with Generalized Anxiety Disorder (GAD) during adulthood were almost 5 and 7 times as likely to score above threshold on the DTS whereas women were >3 times as likely in the presence of ADHD symptoms in childhood or depression during adulthood. This study underscores the need to improve understanding of the clinical manifestations of trauma and co-occurring psychiatric conditions for appropriate sex sensitive interventions targeting Latinos living in prisons.

The association between personality disorders with alcohol use and misuse: A population-based twin study

BACKGROUND

A clearer understanding of the etiological overlap between DSM-IV personality disorders (PDs) and alcohol use (AU) and alcohol use disorder (AUD) is needed. To our knowledge, no study has modeled the association between all 10 DSM-IV PDs and lifetime AU and AUD. The aim of the present study is to identify which PDs are most strongly associated with the phenotypic, genetic, and environmental risks of lifetime AU and AUD, and to determine if these associations are stable across time.

METHODS

Participants were Norwegian twins assessed at two waves. At Wave 1, 2801 twins were assessed for all 10 DSM-IV PD criteria, lifetime AU, and DSM-IV AUD criteria. At Wave 2, six of the 10 PDs were again assessed along with AU and AUD among 2393 twins. Univariate and multiple logistic regressions were run. Significant predictors were further analyzed using bivariate twin Cholesky decompositions.

RESULTS

Borderline and antisocial PD criteria were the strongest predictors of AU and AUD across the two waves. Despite moderate phenotypic and genetic correlations, genetic variation in these PD criteria explained only 4% and 3% of the risks in AU, and 5% to 10% of the risks in AUD criteria, respectively. At Wave 2, these estimates increased to 8% and 23% for AU, and 17% and 33% for AUD.

CONCLUSIONS

Among a large Norwegian twin sample, borderline and antisocial PD criteria were the strongest predictors of the phenotypic and genotypic liability to AU and AUD. This effect remained consistent across time.

The structure of feared social situations among race-ethnic minorities and Whites with social anxiety disorder in the United States

We investigated feared social situations in individuals with social anxiety disorder from different racial and ethnic groups in the United States. The sample included 247 African Americans, 158 Latinos, and 533 non-Latino Whites diagnosed with social anxiety disorder within the past 12 months from the integrated Collaborative Psychiatric Epidemiology Studies data set. After randomly splitting the full sample, we conducted an exploratory factor analysis with half of the sample to determine the structure of feared social situations in a more diverse sample than has been used in previous studies. We found evidence for a model consisting of three feared social domains: performance/public speaking, social interaction, and observational. We then conducted a confirmatory factor analysis on the remaining half of the sample to examine whether this factor structure varied significantly between the race-ethnic groups. Analyses revealed an adequate fit of this model across all three race-ethnic groups, suggesting invariance of the factor structure between the study groups. Broader cultural contexts within which these findings are relevant are discussed, along with important implications for comprehensive, culturally sensitive assessment of social anxiety.

Reliability of ADDIS for diagnoses of substance use disorders according to ICD-10, DSM-IV and DSM-5: test-retest and inter-item consistency

Background

This study investigates test-retest and inter-item consistency of Alcohol Drog Diagnos InStrument (ADDIS), a structured interview to diagnose substance use disorders according to ICD-10, DSM-IV and DSM-5. ADDIS, the Swedish version of SUDDS, is the only instrument in Swedish that produces diagnostic proposals specific to all drug categories, and for all three diagnostic systems. Screening of stressful life events, anxiety, and depression is also included.

Methods

Thirty patients at addiction treatment facilities were interviewed for diagnostic assessment and re-interviewed after one week.

Results

ADDIS has excellent internal consistency. There is also very high test-retest correlation on number of fulfilled criteria for all diagnostic systems. Agreement of diagnostic proposals is substantial, mean absolute agreement is excellent, and mean systematic correlation is almost perfect.

Conclusion

ADDIS is a reliable tool for specific diagnostic assessment of SUDs.

Exploring the relationship between religious service attendance, mental disorders, and suicidality among different ethnic groups: results from a nationally representative survey

BACKGROUND

To date, sufficient data have not been available to examine ethnic differences in religiosity and mental health in the general population. However, evidence exists to suggest that the protective effects of religion may differ across ethnic groups. This study examined the relationship between religious attendance and mental health across ethnic groups.

METHODS

The Collaborative Psychiatric Epidemiologic Survey (N = 20,130) is a large, ethnically diverse sample of adult, US respondents. Frequency of attendance at religious services was measured as: at least once per week (reference group), one to three times per month, less than once per month, or less than once per year. Multiple logistic regression analyses examined associations between religious attendance and mood, anxiety and substance use disorders, as well as suicidal ideation and attempts. Models adjusted for sociodemographics and comorbidity.

RESULTS

Results differed when performed within each ethnicity. Infrequent religious attendance was associated with substance use disorders in Whites and Africans only (Adjusted Odds Ratio (AOR) = 2.30 [95% CI = 1.77-2.99]; AOR = 1.86 [1.25-2.79], respectively), and with anxiety and suicidal ideation in Whites (AOR = 1.44 [1.10-1.88]; AOR = 1.58 [1.24-2.01]) and Hispanics only (AOR = 2.35 [1.17-4.73]; AOR = 1.70 [1.15-2.52]). Asians were the only group in which religious attendance was associated with mood disorders (AOR = 4.90 [1.54-15.60]). Interaction terms were nonsignificant.

CONCLUSIONS

The present study suggests that ethnicity is an important variable to consider in the relationship between religiosity and mental health. Future studies should attempt to either adjust for or stratify by ethnicity when examining these relationships.

Performance-based contracting and the moderating influence of caseworker role overload on service provision in child welfare

Although performance-based contracts have become increasingly popular in child welfare, administrators are developing these contracts with little empirically guided information about how internal work conditions may influence the services families receive. This study examines how child welfare caseworker role overload moderates associations between child welfare agencies' use of performance-based contracting and services provided to families. Analyses using data from the National Survey of Child and Adolescent Well-Being suggest that when caseworkers experience high role overload, use of performance-based contracts may decrease caregivers' likelihood of receiving necessary social and behavioral health services. These findings and their implications are discussed.

The DrugCheck Problem List: a new screen for substance use disorders in people with psychosis

Despite considerable recent interest in the issue of comorbid substance use disorders in people with serious mental illness, there remains a need to refine approaches to screening. This paper describes the development and testing of a new screen for substance-related comorbidity, the 12-item DrugCheck Problem List (PL). Exploratory factor analysis with inpatient samples suggested a single-factor structure, although confirmatory factor analysis in a further sample found similar fit from a two-factor model. Sensitivity and specificity in detecting DSM-IV substance use disorders were both high and comparable to performances of the Severity of Dependence Scale and Alcohol Use Disorders Identification Test (Australian version). The list of problem areas provided by the PL has utility in driving further assessment and treatment planning, and offers suggested foci for motivational interviewing. While further testing is indicated, these data provide strong initial support for its use.

Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness

Women have consistently higher prevalence rates of anxiety disorders, but less is known about how gender affects age of onset, chronicity, comorbidity, and burden of illness. Gender differences in DSM-IV anxiety disorders were examined in a large sample of adults (N=20,013) in the United States using data from the Collaborative Psychiatric Epidemiology Studies (CPES). The lifetime and 12-month male:female prevalence ratios of any anxiety disorder were 1:1.7 and 1:1.79, respectively. Women had higher rates of lifetime diagnosis for each of the anxiety disorders examined, except for social anxiety disorder which showed no gender difference in prevalence. No gender differences were observed in the age of onset and chronicity of the illness. However, women with a lifetime diagnosis of an anxiety disorder were more likely than men to also be diagnosed with another anxiety disorder, bulimia nervosa, and major depressive disorder. Furthermore, anxiety disorders were associated with a greater illness burden in women than in men, particularly among European American women and to some extend also among Hispanic women. These results suggest that anxiety disorders are not only more prevalent but also more disabling in women than in men.

Potential cognitive endophenotypes in multigenerational families: segregating ADHD from a genetic isolate

Endophenotypes are neurobiological markers cosegregating and associated with illness. These biomarkers represent a promising strategy to dissect ADHD biological causes. This study was aimed at contrasting the genetics of neuropsychological tasks for intelligence, attention, memory, visual-motor skills, and executive function in children from multigenerational and extended pedigrees that cluster ADHD in a genetic isolate. In a sample of 288 children and adolescents, 194 (67.4%) ADHD affected and 94 (32.6%) unaffected, a battery of neuropsychological tests was utilized to assess the association between genetic transmission and the ADHD phenotype. We found significant differences between affected and unaffected children in the WISC block design, PIQ and FSIQ, continuous vigilance, and visual-motor skills, and these variables exhibited a significant heritability. Given the association between these neuropsychological variables and ADHD, and also the high genetic component underlying their transmission in the studied pedigrees, we suggest that these variables be considered as potential cognitive endophenotypes suitable as quantitative trait loci (QTLs) in future studies of linkage and association.

The structure of genetic and environmental risk factors for syndromal and subsyndromal common DSM-IV axis I and all axis II disorders

OBJECTIVE

The authors sought to clarify the structure of the genetic and environmental risk factors for 22 DSM-IV disorders: 12 common axis I disorders and all 10 axis II disorders.

METHOD

The authors examined syndromal and subsyndromal axis I diagnoses and five categories reflecting number of endorsed criteria for axis II disorders in 2,111 personally interviewed young adult members of the Norwegian Institute of Public Health Twin Panel.

RESULTS

Four correlated genetic factors were identified: axis I internalizing, axis II internalizing, axis I externalizing, and axis II externalizing. Factors 1 and 2 and factors 3 and 4 were moderately correlated, supporting the importance of the internalizing-externalizing distinction. Five disorders had substantial loadings on two factors: borderline personality disorder (factors 3 and 4), somatoform disorder (factors 1 and 2), paranoid and dependent personality disorders (factors 2 and 4), and eating disorders (factors 1 and 4). Three correlated environmental factors were identified: axis II disorders, axis I internalizing disorders, and externalizing disorders versus anxiety disorders.

CONCLUSIONS

Common axis I and II psychiatric disorders have a coherent underlying genetic structure that reflects two major dimensions: internalizing versus externalizing, and axis I versus axis II. The underlying structure of environmental influences is quite different. The organization of common psychiatric disorders into coherent groups results largely from genetic, not environmental, factors. These results should be interpreted in the context of unavoidable limitations of current statistical methods applied to this number of diagnostic categories.

A cross-ethnic comparison of lifetime prevalence rates of anxiety disorders

To examine race-ethnic differences in the lifetime prevalence rates of common anxiety disorders, we examined data from the Collaborative Psychiatric Epidemiology Studies. The samples included 6870 White Americans, 4598 African Americans, 3615 Hispanic Americans, and 1628 Asian Americans. White Americans were more likely to be diagnosed with social anxiety disorder, generalized anxiety disorder, and panic disorder than African Americans, Hispanic Americans, and Asian Americans. African Americans more frequently met criteria for post-traumatic stress disorder (PTSD) than White Americans, Hispanic Americans, and Asian Americans. Asian Americans were also less likely to meet the diagnoses for generalized anxiety disorder and PTSD than Hispanic Americans, and were less likely to receive social anxiety disorder, generalized anxiety disorder, panic disorder, and PTSD diagnoses than White Americans. The results suggest that race and ethnicity need to be considered when assigning an anxiety disorder diagnosis. Possible reasons for the observed differences in prevalence rates between racial groups are discussed.

A cross-ethnic comparison of lifetime prevalence rates of anxiety disorders

To examine race-ethnic differences in the lifetime prevalence rates of common anxiety disorders, we examined data from the Collaborative Psychiatric Epidemiology Studies. The samples included 6870 White Americans, 4598 African Americans, 3615 Hispanic Americans, and 1628 Asian Americans. White Americans were more likely to be diagnosed with social anxiety disorder, generalized anxiety disorder, and panic disorder than African Americans, Hispanic Americans, and Asian Americans. African Americans more frequently met criteria for post-traumatic stress disorder (PTSD) than White Americans, Hispanic Americans, and Asian Americans. Asian Americans were also less likely to meet the diagnoses for generalized anxiety disorder and PTSD than Hispanic Americans, and were less likely to receive social anxiety disorder, generalized anxiety disorder, panic disorder, and PTSD diagnoses than White Americans. The results suggest that race and ethnicity need to be considered when assigning an anxiety disorder diagnosis. Possible reasons for the observed differences in prevalence rates between racial groups are discussed.

Panic disorder, panic attacks and panic attack symptoms across race-ethnic groups: results of the collaborative psychiatric epidemiology studies

The current study investigates race-ethnic differences in rates of panic disorder, panic attacks and certain panic attack symptoms by jointly combining three major national epidemiological databases. The compared groups were White, African American, Latino and Asian. The White group had significantly higher rates of panic disorder, and of many panic symptoms, including palpitations, as compared to the African American, Asian and Latino groups. Several expected race-ethnic differences were not found. An explanation for these findings are adduced, and suggestions are given for future studies so that possible ethnic-racial differences in panic disorder, panic attacks and panic attack symptoms can be investigated in a more rigorous manner.

The Cannabis Use Problems Identification Test (CUPIT): development, reliability, concurrent and predictive validity among adolescents and adults

AIMS

To describe the empirical construction and initial validation of the Cannabis Use Problems Identification Test (CUPIT), a brief self-report screening instrument for detection of currently and potentially problematic cannabis use.

DESIGN

In a three-phase prospective design an item pool of candidate questions was generated from a literature review and extensive expert consultation. The CUPIT internal structure, cross-sectional and longitudinal psychometric properties were then systematically tested among heterogeneous past-year users.

PARTICIPANTS

Volunteer participants were 212 high-risk adolescents (n = 138) and adults (n = 74) aged 13-61 years from multiple community settings.

MEASUREMENTS

The comprehensive assessment battery included several established measures of cannabis-related pathology for CUPIT validation, with DSM-IV/ICD-10 diagnoses of cannabis use disorders as criterion standard.

FINDINGS

Sixteen items loading highly on two subscales derived from principal components analysis exhibited good to excellent test-retest (0.89-0.99) and internal consistency reliability (0.92, 0.83), and highly significant ability to discriminate diagnostic subgroups along the severity continuum (non-problematic, risky, problematic use). Twelve months later, baseline CUPIT scores demonstrated highly significant longitudinal predictive utility for respondents' follow-up diagnostic group membership. Receiver operating characteristic (ROC) analysis identified a CUPIT score of 12 to be the optimal cut-point for maximizing sensitivity for both currently diagnosable cannabis use disorder and those at risk of meeting diagnostic criteria in the following 12 months.

CONCLUSIONS

The CUPIT is a brief cannabis screener that is reliable, valid and acceptable for use across diverse community settings and consumers of all ages. The CUPIT has clear potential to assist with achievement of public health goals to reduce cannabis-related harms in the community.

Significance of endorsement of psychotic symptoms by US Latinos

In US regional studies, Latinos frequently endorse psychotic symptoms associated with impairment and mental health service use, yet do not meet criteria for psychotic disorder. Using a nationally representative Latino sample (N = 2554), we examined the prevalence of psychotic symptoms, their relationship to psychotic disorder, their correlates, and their relationship to mental health outcomes. In this sample, 9.5% (SE = 0.7) endorsed 1 or more lifetime psychotic symptoms, yet 93% of endorsers did not meet Structured Clinical Interview for DSM-IV criteria for psychotic disorders. Endorsement was associated with physical and emotional distress, particularly lifetime anxiety and current substance use disorder. Acculturation to US society and reliance on spiritual/religious help were also associated with psychotic symptom endorsement. These symptoms have substantial clinical significance, being independently associated with suicidal ideation, mental health-related disability, and outpatient mental health service utilization. Endorsed psychotic symptoms in Latinos may constitute a clinically significant marker of general psychiatric vulnerability rather than a sign of psychotic disorder.

Early intervention for adolescents with borderline personality disorder: quasi-experimental comparison with treatment as usual

OBJECTIVE

The aim of the present study was to compare the effectiveness of specialized team-based early intervention for borderline personality disorder (BPD) with treatment as usual.

METHOD

In a quasi-experimental design, 32 outpatients who received historical treatment as usual (H-TAU) were compared with 78 participants from a recently published randomized controlled trial of cognitive analytic therapy (CAT; n = 41) versus manualized good clinical care (GCC; n = 37), conducted in a specialized early intervention service for BPD (the Helping Young People Early (HYPE) programme). All participants were 15-18-year-old outpatients who fulfilled 2-9 DSM-IV BPD criteria. It was predicted that, compared with H-TAU, HYPE + GCC and HYPE + CAT would show greater reductions in psychopathology and parasuicidal behaviour and greater improvement in global functioning over 24 months.

RESULTS

At 24 month follow up: (i) HYPE + CAT had lower standardized levels of, and a significantly faster standardized rate of improvement in, internalizing and externalizing psychopathology, compared with H-TAU; and (ii) HYPE + GCC had lower standardized levels of internalizing psychopathology and a faster rate of improvement in global functioning than H-TAU. HYPE + CAT yielded the greatest median improvement on the four continuous outcome measures over 24 months. No adverse effects were shown with any of the treatments.

CONCLUSIONS

Specialized early intervention for subsyndromal or full-syndrome BPD is more effective than TAU, with HYPE + CAT being the most effective intervention. Reform of existing services using the HYPE model might yield substantial improvements in patient outcomes.

The effect of comorbid substance use disorders on treatment outcome for anxiety disorders

This study examined the impact of concurrent substance use disorders (SUDs) on outcomes for psychotherapy targeting anxiety disorders. Study 1 (N=484) sought to determine the prevalence of SUDs in a sample referred to a community anxiety disorders clinic, as well as the impact of comorbid SUDs on outcomes for a subsample (n=200) completing cognitive behavior therapy (CBT). Around one-quarter (22-29%) of patients with one or two anxiety disorders met criteria for at least one SUD, but this rate was substantially higher (46%) for patients with three anxiety disorders. Concurrent SUDs were associated with higher levels of anxiety but not depression or stress, compared to those without a SUD. However, concurrent SUDs did not moderate treatment outcomes. Study 2 (N=103) focused on the impact of alcohol use on diagnosis-specific symptom measures and generic measures of distress and disability, following a course of CBT for panic disorder or social phobia. Pre-treatment alcohol use did not predict changes in panic symptoms, performance anxiety, distress, or disability, but it did predict changes in social interaction anxiety. Problem drinking per se did not have any predictive utility in terms of treatment outcome. These findings suggest that clinicians treating patients for a primary anxiety disorder and concurrent SUD can be relatively optimistic about treatment outcomes.

Assessing addiction: concepts and instruments

Efficient, organized assessment of substance use disorders is essential for clinical research, treatment planning, and referral to adjunctive services. In this article, we discuss the basic concepts of formalized assessment for substance abuse and addiction, as established by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, and describe six widely used structured assessment instruments. Our aim is to help researchers and clinical programs identify the instruments that best suit their particular situations and purposes.

Psychiatric comorbidity and acculturation stress among Puerto Rican substance abusers

BACKGROUND

Although acculturation to the United States has been associated with an increase in substance, mood, and anxiety disorders in Latino populations, few studies have examined this concept relative to comorbidity among these syndromes.

METHODS

This study compares the prevalence and patterns of psychiatric comorbidity among Puerto Ricans with substance use disorders living in San Juan (Puerto Rico) to those who have migrated to New Haven (Connecticut) and examines the association between acculturation-related stress and the prevalence and patterns of psychiatric comorbidity among those who have migrated to New Haven.

RESULTS

Lifetime levels of nearly all comorbid psychiatric disorders among respondents with substance use disorders were generally similar across sites. However, the risk of any co-occurring psychiatric disorder was higher among substance use disorder cases in New Haven who reported high levels of total acculturation stress and family-specific acculturation stress. These findings were generally accounted for by associations between affective disorders and high scores on these indicators of acculturation stress.

CONCLUSIONS

The overall prevalence and patterns of psychiatric comorbidity are remarkably similar among Puerto Rican substance abusers whether they live in San Juan or have migrated to New Haven, thereby demonstrating robustness to differences in geographic location. Nevertheless, the degree of acculturation-related family stress is positively associated with co-occurring substance and psychiatric disorders, particularly affective disorders. Intervention in family strain related to the acculturation process may diminish the development of comorbid mental disorders and assist in implementing successful treatment of substance abuse.

Co-occurrence of mental and physical illness in US Latinos

BACKGROUND

This study describes the prevalence of comorbid physical and mental health problems in a national sample of US Latinos. We examined the co-occurrence of anxiety and depression with prevalent physical chronic illnesses in a representative sample of Latinos with national origins from Mexico, Cuba, Puerto Rico, and other Latin American countries.

METHOD

We used data on 2,554 Latinos (75.5% response rate) ages 18 years and older from the National Latino and Asian American Study (NLAAS). The NLAAS was based on a stratified area probability sample design, and the sample came from the 50 states and Washington, DC. Survey questionnaires were delivered both in person and over the telephone in English and Spanish. Psychiatric disorders were assessed using the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI). Physical chronic illness was assessed by self-reported history.

RESULTS

Puerto Ricans had the highest prevalence of meeting criteria for any comorbid psychiatric disorder (more than one disorder). Puerto Ricans had the highest prevalence (22%) of subject-reported asthma history, while Cubans had the highest prevalence (33%) of cardiovascular disease. After accounting for age, sex, household income, number of years in the US, immigrant status, and anxiety or depression, anxiety was associated with diabetes and cardiovascular disease, in the entire sample. Depression and co-occurring anxiety and depression were positively associated with having a history of asthma but not with other physical diseases, in the entire sample. Interestingly, Puerto Ricans with a depressive disorder had a lower odds of having a history of cardiovascular disease than Puerto Ricans without a depressive disorder. The relationship between chronic physical and mental illness was not confounded by immigration status or number of years in the US.

DISCUSSION

Despite previous findings that link acculturation with both chronic physical and mental illness, this study does not find that number of years in the US nor nativity explain the prevalence of psychiatric-medical comorbidities. This study demonstrates the importance of considering psychiatric and medical comorbidity among specific ethnic groups, as different patterns emerge than when using aggregate ethnic measures. Research is needed on both the pathways and the mechanisms of comorbidity for the specific Latino groups.

Correlates of past-year mental health service use among Latinos: results from the National Latino and Asian American Study

OBJECTIVES

We examined correlates and rates of past-year mental health service use in a national sample of Latinos residing in the United States.

METHODS

We used data from the National Latino and Asian American Study, a national epidemiological household survey of Latinos.

RESULTS

Cultural factors such as nativity, language, age at migration, years of residence in the United States, and generational status were associated with whether or not Latinos had used mental health services. However, when the analysis was stratified according to past-year psychiatric diagnoses, these associations held only among those who did not fulfill criteria for any of the psychiatric disorders assessed. Rates of mental health service use among those who did not fulfill diagnostic criteria were higher among Puerto Ricans and US-born Latinos than among non-Puerto Ricans and foreign-born Latinos.

CONCLUSIONS

Rates of mental health service use among Latinos appear to have increased substantially over the past decade relative to rates reported in the 1990s. Cultural and immigration characteristics should be considered in matching mental health services to Latinos who need preventive services or who are symptomatic but do not fulfill psychiatric disorder criteria.

Association between parental and individual psychiatric/substance use disorders and smoking stages among Puerto Rican adolescents

OBJECTIVE

To examine the associations between parental and individual psychiatric disorders and smoking stages among Puerto Rican youth from migrant and non-migrant families.

METHOD

Analyses were conducted drawing on data collected as part of a migrant family study examining youth at high and low risk for substance use disorders based on the presence or absence of a parental history of substance abuse or dependence. Parents and their offspring were recruited in San Juan, Puerto Rico (n=450) and New Haven, CT, USA (n=350).

RESULTS

Experimental smoking among adolescent offspring was associated with parent proband disorders. In contrast, regular smoking behavior, defined as at least weekly smoking for a month or more, and DSM-IV nicotine dependence were more strongly associated with the adolescents' own psychiatric disorders. With the exception of anxiety disorders, significant bivariate associations were shown between each psychiatric/substance use disorder and nicotine dependence. Once comorbidity was statistically controlled, only attention deficit hyperactivity disorder (ADHD), and alcohol and drug use disorders were significantly associated with nicotine dependence. After controlling for adolescents' psychiatric comorbidity, there was an association between parental disorders and both experimental and regular smoking in their adolescent offspring.

CONCLUSIONS

By combining family and migrant research strategies within a single study, the present investigation was able to simultaneously examine familial, individual and sociocultural factors that may play a role in development and/or persistence of smoking behavior among Puerto Rican adolescents.

Illicit psychoactive substance use, abuse and dependence in a population-based sample of Norwegian twins

BACKGROUND

Prior population-based twin studies from two Anglophonic countries with relatively high rates of drug use - the USA and Australia - suggest that genetic factors contribute substantially to individual differences in the use, abuse and dependence of illicit psychoactive substances. Would these results replicate in Norway, a Nordic country with a low prevalence of illicit drug use?

METHOD

Lifetime use, abuse and dependence of five illicit drug categories (cannabis, stimulants, opiates, cocaine and psychedelics) were assessed at personal interview in 1386 complete young adult twin pairs ascertained from the Norwegian Institute of Public Health Twin Panel. Twin model fitting was performed using the Mx statistical package on three phenotypes: any lifetime use, endorsement of at least one DSM-IV symptom of abuse or dependence, and meeting DSM-IV criteria for abuse or dependence.

RESULTS

Significant lifetime use of illicit substances (defined as use 10 or more times) was reported by only 6.4% of the sample. Meaningful analyses were possible for use of any substance and each of the five substances individually, but for symptoms or a diagnosis of abuse/dependence meaningful analyses were possible only for any substance and cannabis. Full twin models uniformly found twin resemblance to be due largely or entirely to genetic factors. Best-fit models for all analyses included only genetic and individual-specific environmental effects with heritability estimates ranging from 58% to 81%.

CONCLUSION

In accord with prior results from the USA and Australia, genetic factors appear to play an important role in the etiology of use and abuse/dependence of illicit drugs in Norway.

Managed care and systems cost-effectiveness: treatment for depression

OBJECTIVE

The objective of this study was to assess the change in system cost-effectiveness of depression treatment after the introduction of managed care.

DATA SOURCES/STUDY SETTING

The study population consisted of adults ages 18 to 69 living in low-income areas of Puerto Rico.

STUDY DESIGN

Using a random probability sample of the population, 2 waves (1992-1993, 1993-1994) of data were collected before implementation of managed care and one wave (1996-1998) after implementation. Composite International Diagnostic Interview (CIDI)-generated depression diagnoses and Centers for Epidemiologic Studies-Depression (CES-D) scale of depressive symptoms scales were used to assess depression.

DATA COLLECTION/EXTRACTION METHODS

Effectiveness of treatment was defined by guideline standards and experts' assessment of the probability of remission resulting from treatment. Costs were measured by assigning representative prices to each treatment modality. Difference-in-difference (D-in-D) estimators were used to assess the impact of managed care on the effectiveness and costs of treating depression at the system level for the entire population.

PRINCIPAL FINDINGS

System cost-effectiveness improved slightly after the introduction of managed care, with diminished costs but no significant improvements in effectiveness.

CONCLUSION

Cost-effectiveness can be measured at the population level to assess system changes. Additional incentives and system realignments beyond utilization review and diminished treatment costs are necessary to attain a more cost-effective system of care.

Understanding hard-core drug use among urban Puerto Rican women in high-risk neighborhoods

The objectives of the current study were to determine the incidence and prevalence of hard-core drug (HCD) use and to explore the predictors of HCD use in a three-wave longitudinal study of women ages 18-35 living in urban areas of high drug traffic in Puerto Rico. Prevalence of HCD use was determined by positive self-report or positive toxicological tests for crack, cocaine, or heroine at baseline and follow-up periods. Incidence density was calculated using Poisson methods. Predictors of HCD use were identified using the generalized estimating equation (GEE) approach. Prevalence rates fluctuated between 16.3 at baseline and 12.6 and 14.6 at subsequent waves. Incidence of crack/cocaine or heroine ranged from 7.4 to 6.3 per 100 person years. Low education, unemployment, current alcohol use, and severe partner violence predict incident HCD use. Therefore, prevention programs for HCD use must consider strategies to promote social mobility and empowerment and to mitigate violence against women.

On beyond urine: clinically useful assessment instruments in the treatment of drug dependence

Although there are a wealth of clinically useful, brief, and low-cost assessment instruments available for use with drug-dependent populations, relatively few are broadly used in clinical practice. With an emphasis on: (1). the multidimensional nature of drug users' problems; and (2). assessments that can be integrated into empirically validated treatments, clinically useful assessments in four general categories (evaluation and diagnosis of drug dependence, identifying concurrent disorders and problems, treatment planning, and evaluation of treatment outcome) are briefly summarized. Progress in the field of drug abuse treatment has been significantly hampered by the failure to adopt, across research and clinical settings, a common set of assessments.

Prevalence and correlates of substance use disorders among older adolescents in Puerto Rico and the United States: a cross-cultural comparison

Although there are substantial data on adolescent substance use, little systematic research has studied the prevalence of adolescent substance disorders in general populations, let alone cultural differences in disorder prevalence. In this paper we report the prevalence and correlates of alcohol and drug use and disorder among older adolescents on Puerto Rico (PR) and in the United States (US). Data come from an island-wide survey of the PR general residential population (15-18 year old subsample, unweighted N=922) fielded in 1997, and from the National Comorbidity Survey of the US household population (15-18 year old subsample, unweighted N=641), fielded in 1991. Both surveys used a similar standardized interview based on the Composite International Diagnostic Interview (CIDI) to generate DSM-IV diagnoses. Bivariate analyses and logistic regression were used. The major findings are: (1) US youth report higher rates of lifetime alcohol and drug use and substance-related disorder than PR youth; (2) the transition to abuse or dependence occurs for one-third of US drinkers, one-fifth of drinkers in PR, and about one-half of the drug users in both US and PR; (3) there are marked variations across sites in the types of symptoms substance users are likely to experience; (4) with the exception of family income, most correlates operate similarly in both sub-samples; and (5) the majority of both US and PR youth with a past year substance use disorder did not report any service utilization in the past year.