Using Lithium in Children and Adolescents with Bipolar Disorder: Efficacy, Tolerability, and Practical Considerations

Lithium has been an intriguing treatment option in psychiatry for over a century. While seemingly just a simple elemental compound, it has powerful treatment effects for both depression and bipolar disorder. The evidence base for treatment of pediatric bipolar disorder is relatively small, but, in recent years, additional clinical trial data have enabled lithium to re-emerge as a valuable and, in many cases, preferred treatment. Pharmacologically, lithium is complex, with varied effects at both intracellular and extracellular levels. As a treatment for bipolar disorder in pediatrics, lithium is challenging, given its narrow therapeutic window and myriad of potential side effects. However, the efficacy of lithium continues to match that of newer pharmacologic agents, and its tolerability has been shown to be comparable with more commonly prescribed medications. Lithium is still one of few drugs that have been proven to reduce the risk of suicidality, and it may have utility in illnesses beyond affective disorders. Practically, as a primary agent or as an adjunct, lithium continues to claim a rightful place in the treatment armamentarium of child psychiatry. New dosing paradigms have improved tolerability and reduced potential side effects. Recent evidence affirms that lithium is effective for pediatric bipolar disorder in multiple phases of the illness.

The recycling endosome protein RAB-10 promotes autophagic flux and localization of the transmembrane protein ATG-9

Macroautophagy/autophagy involves the formation of an autophagosome, a double-membrane vesicle that delivers sequestered cytoplasmic cargo to lysosomes for degradation and recycling. Closely related, endocytosis mediates the sorting and transport of cargo throughout the cell, and both processes are important for cellular homeostasis. However, how endocytic proteins functionally intersect with autophagy is not clear. Mutations in the DAF-2/insulin-like IGF-1 (INSR) receptor at the permissive temperature result in a small increase in GFP::LGG-1 foci, i.e. autophagosomes, but a large increase at the nonpermissive temperature, allowing us to control the level of autophagy. In a RNAi screen for endocytic genes that alter the expression of GFP::LGG-1 in daf-2 mutants, we identified RAB-10, a small GTPase that regulates basolateral endocytosis. Loss of rab-10 in daf-2 mutants results in more GFP::LGG-1-positive foci at the permissive, but less GFP::LGG-1 or SQST-1::GFP foci at the nonpermissive temperature. As previously reported, loss of rab-10 alone resulted in an increase of GFP:LGG-1 foci. Exposure of rab-10 mutant animals to chloroquine, a known inhibitor of autophagic flux, failed to increase the number of GFP::LGG-1 foci. Moreover, colocalization between LMP-1::tagRFP and GFP::LGG-1 (the lysosome and autophagosome reporters) was decreased in daf-2; rab-10 dauers at the nonpermissive temperature. Intriguingly, RAB-10 was required to maintain the normal size of GFP::ATG-9-positive structures in daf-2 mutants at both the permissive and nonpermissive temperature. Finally, we found that RAB-10 GTPase cycling was required to control the size of GFP::ATG-9 foci. Collectively, our data support a model where rab-10 controls autophagic flux by regulating autophagosome formation and maturation.

Supporting families of critically ill children at home using videoconferencing

Home videoconferencing links for families of children recently discharged with complex congenital heart disease may be useful in monitoring potentially unstable patients. A randomized controlled trial was carried out comparing home videoconferencing with telephone contact. Patients were randomized to an interventional videoconferencing group (n= 14), or to one of two control groups: the first (n = 9) received the same ad hoc telephone support that was available to all patients; the second group (n = 1 3) received regular telephone calls with the same protocol as those in the videoconferencing group. The results from the trial are still being analysed. Our experience with commercial cable modem transmission quickly showed that this is an unsuitable modality. Preliminary results with ISDN videoconferencing are encouraging. Initial results and feedback from families strongly suggest that videoconferencing provides significant benefits over telephone follow-up.

Gender distribution, sexual size dimorphism and morphometric sexing in ballan wrasse Labrus bergylta

In wild ballan wrasse Labrus bergylta, mass-length relationships were not different between genders, and positive allometry was found in the mixed-gender population. Male-biased sexual size dimorphism was significant and the most effective morphometric method for sexing L. bergylta outside of the species spawning window used body mass (M(B) in g), total body length (L(T) in mm) and Fulton's condition factor (K) as discriminant variables to predict gender with 91% accuracy. The discriminant score (S(D)) of a specimen can be calculated as S(D)  = 0.01 M(B)- 0.016 L(T)- 3.835 K + 6.252 to predict its gender as female or male if S(D) is < 1.459 or S(D) is > 1.504, respectively. There was a potential trend towards earlier sexual inversion compared to previous studies at comparable latitudes. Sex change is a phenotypically plastic trait under social control in haremic fishes and should be monitored in increasingly exploited L. bergylta.

Burden of disease associated with alcohol use disorders in the United States

BACKGROUND

Alcohol use disorders (AUD) have long been considered to be some of the most disabling mental disorders; however, empirical data on the burden of disease associated with AUD have been sparse. The objective of this article is to quantify the burden of disease (in disability-adjusted life years [DALYs] lost), deaths, years of life lost due to premature mortality (YLL), and years of life lost due to disability (YLD) associated with AUD for the United States in 2005.

METHODS

Statistical modeling was based on epidemiological indicators derived from the National Epidemiologic Survey on Alcohol and Related Conditions. Formal consistency analyses were applied. Risk relations were taken from recent meta-analyses and the disability weights from the burden of disease study of the National Institutes of Health. Monte Carlo simulations were used to derive confidence intervals. All analyses were performed by sex and age. Sensitivity analyses were undertaken on key indicators.

RESULTS

In the United States in 2005, 65,000 deaths, 1,152,000 YLL, 2,443,000 YLD, and 3,595,000 DALYs were associated with AUD. For individuals 18 years of age and older, AUD were associated with 3% of all deaths (5% for men and 1% for women), and 5% of all YLL (7% for men and 2% for women). The majority of the burden of disease associated with AUD stemmed from YLD, which accounted for 68% of DALYs associated with AUD (66% for men and 74% for women). The youngest age group had the largest proportion of DALYs associated with AUD stemming from YLD.

CONCLUSIONS

Using data from a large representative survey (checked for consistency) and by combining these data with the best available evidence, we found that AUD were associated with a larger burden of disease than previously estimated. To reduce this disease burden, implementation of prevention interventions and expansion of treatment are necessary.

A compact high-performance low-field NMR apparatus for measurements on fluids at very high pressures and temperatures

We discuss an innovative new high-performance apparatus for performing low-field Nuclear Magnetic Resonance (NMR) relaxation times and diffusion measurements on fluids at very high pressures and high temperatures. The apparatus sensor design and electronics specifications allow for dual deployment either in a fluid sampling well logging tool or in a laboratory. The sensor and electronics were designed to function in both environments. This paper discusses the use of the apparatus in a laboratory environment. The operating temperature and pressure limits, and the signal-to-noise ratio (SNR) of the new system exceed by a very wide margin what is currently possible. This major breakthrough was made possible by a revolutionary new sensor design that breaks many of the rules of conventional high pressure NMR sensor design. A metallic sample holder capable of operating at high pressures and temperatures is provided to contain the fluid under study. The sample holder has been successfully tested for operation up to 36 Kpsi. A solenoid coil wound on a slotted titanium frame sits inside the metallic sample holder and serves as an antenna to transmit RF pulses and receive NMR signals. The metal sample holder is sandwiched between a pair of gradient coils which provide a linear field gradient for pulsed field gradient diffusion measurements. The assembly sits in the bore of a low-gradient permanent magnet. The system can operate over a wide frequency range without the need for tuning the antenna to the Larmor frequency. The SNR measured on a water sample at room temperature is more than 15 times greater than that of the commercial low-field system in our laboratory. Thus, the new system provides for data acquisition more than 200 times faster than was previously possible. Laboratory NMR measurements of relaxations times and diffusion coefficients performed at pressures up to 25 Kpsi and at temperatures up to 175 °C with crude oils enlivened with dissolved hydrocarbon gases (referred to as "live oils") are shown. This is the first time low-field NMR measurements have been performed at such high temperatures and pressures on live crude oil samples. We discuss the details of the apparatus design, tuning, calibration, and operation. NMR data acquired at multiple temperatures and pressures on a live oil sample are discussed.

The state of US health, 1990-2010: burden of diseases, injuries, and risk factors

IMPORTANCE

Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy.

OBJECTIVES

To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries.

DESIGN

We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages.

RESULTS

US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th.

CONCLUSIONS AND RELEVANCE

From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations.

Thought disorder in the meta-structure of psychopathology

BACKGROUND

Dimensional models of co-morbidity have the potential to improve the conceptualization of mental disorders in research and clinical work, yet little is known about how relatively uncommon disorders may fit with more common disorders. The present study estimated the meta-structure of psychopathology in the US general population focusing on the placement of five under-studied disorders sharing features of thought disorder: paranoid, schizoid, avoidant and schizotypal personality disorders, and manic episodes as well as bipolar disorder.

METHOD

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a face-to-face interview of 34 653 non-institutionalized adults in the US general population. The meta-structure of 16 DSM-IV Axis I and Axis II psychiatric disorders, as assessed by the Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV version (AUDADIS-IV), was examined using exploratory and confirmatory factor analysis.

RESULTS

We document an empirically derived thought disorder factor that is a subdomain of the internalizing dimension, characterized by schizoid, paranoid, schizotypal and avoidant personality disorders as well as manic episodes. Manic episodes exhibit notable associations with both the distress subdomain of the internalizing dimension as well as the thought disorder subdomain. The structure was replicated for bipolar disorder (I or II) in place of manic episodes.

CONCLUSIONS

As our understanding of psychopathological meta-structure expands, incorporation of disorders characterized by detachment and psychoticism grows increasingly important. Disorders characterized by detachment and psychoticism may be well conceptualized, organized and measured as a subdimension of the internalizing spectrum of disorders. Manic episodes and bipolar disorder exhibit substantial co-morbidity across both distress and thought disorder domains of the internalizing dimension. Clinically, these results underscore the potential utility of conceptualizing patient treatment needs using an approach targeting psychopathological systems underlying meta-structural classification rubrics.

Gender differences in lifetime alcohol dependence: results from the national epidemiologic survey on alcohol and related conditions

BACKGROUND

An extensive clinical literature has noted gender differences in the etiology and clinical characteristics of individuals with alcohol dependence (AD). Despite this knowledge, many important questions remain.

METHODS

Using the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093), we examined differences in sociodemographic characteristics, psychiatric and medical comorbidities, clinical correlates, risk factors, and treatment-utilization patterns of men (N = 2,974) and women (N = 1,807) with lifetime AD.

RESULTS

Men with lifetime AD were more likely than women to be diagnosed with any substance use disorder and antisocial personality disorder, whereas women were more likely to have mood and anxiety disorders. After adjusting for sociodemographic characteristics and gender differences in psychiatric comorbidity in the general population, AD was associated with externalizing disorders and any mood disorder among women only. Men with AD met more criteria, had longer episodes, and were younger at the age of first drink. There were no gender differences in remission rates. Women with AD were more likely to have a family and a spouse with history of alcohol use disorders. Treatment rates were low for both genders, and women were more likely to report social stigmatization as a treatment barrier.

CONCLUSIONS

There are important gender differences in the psychiatric comorbidities, risk factors, clinical characteristics, and treatment-utilization patterns among individuals with lifetime AD.

Sex differences in antisocial personality disorder: results from the National Epidemiological Survey on Alcohol and Related Conditions

Despite the 3:1 prevalence ratio of men versus women with Antisocial Personality Disorder (ASPD), research on sex differences on correlates of ASPD in the general population is scarce. The purpose of this study was to examine sex differences in childhood and adult adverse events, lifetime psychiatric comorbidity, and clinical correlates of DSM-IV ASPD. The sample included 819 men and 407 women with DSM-IV ASPD diagnosis. Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (N = 43,093). Compared to men, women with ASPD reported more frequent childhood emotional neglect (AOR = 2.25; 95% CI: 1.52-3.34) and sexual abuse (AOR = 4.20; 95% CI: 2.78-6.35), any parent-related adverse event during childhood (e.g., parental substance use disorder) (AOR = 2.47; 95% CI: 1.60-3.82), and adverse events during adulthood (AOR = 4.20; 95% CI: 2.78-6.35). Although women with ASPD present less violent antisocial behaviors and higher rates of aggressiveness and irritability (OR = 0.46; 95% CI: 0.31-0.67), they have higher rates of victimization, greater impairment, and lower social support. Our findings suggest increased mental health needs in women with ASPD, meriting development of different treatment programs for women and men.

Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign

PURPOSE

Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively.

METHOD

A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction.

RESULTS

Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001).

DISCUSSION

Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time.

METHODS

We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights.

FINDINGS

Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions.

INTERPRETATION

Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results.

FUNDING

Bill & Melinda Gates Foundation.

A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time.

METHODS

We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden.

FINDINGS

In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2-7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5-7·0]), and alcohol use (5·5% [5·0-5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8-9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6-8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4-6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2-10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4-1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania.

INTERPRETATION

Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children.

FUNDING

Bill & Melinda Gates Foundation.

The predictive validity of Cluster C personality disorders on the persistence of major depression in the national epidemiologic survey on alcohol and related conditions

The present study examined the predictive validity of Cluster C personality disorders (CCPDs) on major depressive disorder (MDD), using Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, N = 34,653; time interval equals 3 years). Multiple logistic regression analyses were utilized to compare respondents with MDD and a concurrent CCPD to those with MDD only. Findings demonstrated that individuals with MDD and a comorbid CCPD were significantly more likely than those with MDD only to have MDD at Time 2. The presence of comorbid CCPD in individuals with MDD also predicts the subsequent occurrence of suicide attempts at Time 2 and the new onset of Axis I anxiety disorders. The chronic and enduring personality styles and interpersonal difficulties that characterize individuals with a CCPD likely lead to the exacerbation of MDD symptoms. Clinicians should be aware of the impact that CCPDs have on the outcome of MDD.

Personality disorders and the 3-year course of alcohol, drug, and nicotine use disorders

CONTEXT

Little is known about the role of a broad range of personality disorders in the course of substance use disorder (SUD) and whether these differ by substance. The existing literature focuses mostly on antisocial personality disorder and does not come to clear conclusions.

OBJECTIVE

To determine the association between the 10 DSM-IV personality disorders and the persistence of common SUDs in a 3-year prospective study of a national sample.

DESIGN

Data were drawn from participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) who had alcohol dependence (n = 1172), cannabis use disorder (n = 454), or nicotine dependence (n = 4017) at baseline and who were reinterviewed 3 years later. Control variables included demographic characteristics, family history of substance disorders, baseline Axis I disorders and treatment status, and prior SUD duration. Main Outcome Measure  Persistent SUD, defined as meeting full criteria for the relevant SUD throughout the 3-year follow-up period.

RESULTS

Persistent SUD was found among 30.1% of participants with alcohol dependence, 30.8% with cannabis use disorder, and 56.6% with nicotine dependence at baseline. Axis I disorders did not have strong or consistent associations with persistent SUD. In contrast, antisocial personality disorder was significantly associated with persistent alcohol, cannabis, and nicotine use disorders (adjusted odds ratios, 2.46-3.51), as was borderline personality disorder (adjusted odds ratios, 2.04-2.78) and schizotypal personality disorder (adjusted odds ratios, 1.65-5.90). Narcissistic, schizoid, and obsessive-compulsive personality disorders were less consistently associated with SUD persistence.

CONCLUSIONS

The consistent findings on the association of antisocial, borderline, and schizotypal personality disorders with persistent SUD indicates the importance of these personality disorders in understanding the course of SUD. Future studies should examine dimensional representations of personality disorders and the role of specific components of these disorders, biological and environmental contributors to these relationships, and potential applications of these findings to treatment development.

Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population

While placed on different axes of the DSM classification system, borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) have important relationships with trauma, and overlap between these disorders has long been recognized. The current study is the first to examine comorbidity of PTSD and BPD in a large nationally representative sample using a reliable and valid method of assessing Axis I and II mental disorders. Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave II (N = 34,653; response rate 70.2%). Multiple regression models were used to examine differences in psychopathology, traumatic events and health-related quality of life across individuals with PTSD alone (n = 1820), BPD alone (n = 1290) and those with comorbid PTSD-BPD (n = 643). The lifetime prevalence of PTSD and BPD were 6.6% and 5.9%, respectively. Of individuals with BPD, 30.2% were also diagnosed with PTSD, whereas 24.2% of individuals with PTSD were also diagnosed with BPD. Individuals with comorbid PTSD-BPD had a poorer quality of life, more comorbidity with other Axis I conditions, increased odds of a lifetime suicide attempt, and a higher prevalence of repeated childhood traumatic events than individuals with either condition alone. These results show that PTSD and BPD have a high degree of lifetime co-occurrence but are not entirely overlapping. Their concurrence is associated with poorer functioning compared to either diagnosis alone, emphasizing the clinical utility of diagnosing both conditions. Future research should explore the determinants of having either or both diagnoses with an aim toward improved identification, prevention, and intervention.

A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder

No longitudinal study has examined risk factors for future suicide attempts in major depressive disorder in a nationally representative sample. The objective of this study was to investigate baseline sociodemographic characteristics, comorbid mental disorders, specific depressive symptoms, and previous suicidal behavior as potential risk factors for suicide attempts at 3 years follow-up. Data came from the national epidemiologic survey on alcohol and related conditions (NESARC), a large nationally representative longitudinal survey of mental illness in adults [Wave 1 (2001-2002); Wave 2 (2004-2005) n=34,653]. Logistic regression examined associations between risk factors present at Wave 1 and suicide attempts at Wave 2 (n=169) among individuals with major depressive disorder at baseline assessment (n=6004). Risk factors for incident suicide attempts at Wave 2 (n=63) were identified among those with major depressive disorder at Wave 1 and no lifetime history of suicide attempts (n=5170). Results revealed specific comorbid anxiety, personality, and substance use disorders to be associated with incident suicide attempts at Wave 2. Comorbid borderline personality disorder was strongly associated with suicide attempts in all models. Several comorbid disorders were strongly associated with suicide attempts at Wave 2 even after adjusting for previous suicidal behavior, notably posttraumatic stress disorder (adjusted odds ratio (AOR)=2.20; 95% confidence interval (95% CI) 1.27-3.83) and dependent personality disorder (AOR=4.43; 95% CI 1.93-10.18). These findings suggest that mental illness comorbidity confers an increased risk of future suicide attempts in major depressive disorder that is not solely accounted for by past suicidal behavior.

Prevalence and correlates of fire-setting in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

OBJECTIVE

To estimate the prevalence, sociodemographic correlates, comorbidity, and rates of mental health service utilization of fire-setters in the general population.

METHOD

A face-to-face survey of more than 43,000 adults aged 18 years and older residing in households was conducted during the 2001-2002 period. Diagnoses of mood, anxiety, substance use disorders, and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV).

RESULTS

The prevalence of lifetime fire-setting in the US population was 1.13 (95% CI, 1.0-1.3). Being male, never married, and US-born and having a yearly income over $70,000 were risk factors for lifetime fire-setting, while being Asian or Hispanic and older than 30 years were protective factors for lifetime fire-setting. The strongest associations with fire-setting were with disorders often associated with deficits in impulse control, such as antisocial personality disorder (ASPD) (odds ratio [OR] = 21.8; CI, 6.6-28.5), drug dependence (OR = 7.6; 95% CI, 5.2-10.9), bipolar disorder (OR = 5.6; 95% CI, 4.0-7.9), and pathological gambling (OR = 4.8; 95% CI, 2.4-9.5). Associations between fire-setting and all antisocial behaviors were positive and significant. A lifetime history of fire-setting, even in the absence of an ASPD diagnosis, was strongly associated with substantial rates of Axis I comorbidity, a history of antisocial behavior, a family history of other antisocial behaviors, decreased functioning, and higher treatment-seeking rates.

CONCLUSIONS

Our findings suggest that fire-setting may be better understood as a behavioral manifestation of a broader impaired control syndrome and part of the externalizing spectrum. Fire-setting and other antisocial behaviors tend to be strongly associated with each other and increase the risk of lifetime and current psychiatric disorders, even in the absence of a DSM-IV diagnosis of ASPD.

Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the US example

Background

Alcohol consumption is a major risk factor in the global burden of disease, with overall volume of exposure as the principal underlying dimension. Two main sources of data on volume of alcohol exposure are available: surveys and per capita consumption derived from routine statistics such as taxation. As both sources have significant problems, this paper presents an approach that triangulates information from both sources into disaggregated estimates in line with the overall level of per capita consumption.

Methods

A modeling approach was applied to the US using data from a large and representative survey, the National Epidemiologic Survey on Alcohol and Related Conditions. Different distributions (log-normal, gamma, Weibull) were used to model consumption among drinkers in subgroups defined by sex, age, and ethnicity. The gamma distribution was used to shift the fitted distributions in line with the overall volume as derived from per capita estimates. Implications for alcohol-attributable fractions were presented, using liver cirrhosis as an example.

Results

The triangulation of survey data with aggregated per capita consumption data proved feasible and allowed for modeling of alcohol exposure disaggregated by sex, age, and ethnicity. These models can be used in combination with risk relations for burden of disease calculations. Sensitivity analyses showed that the gamma distribution chosen yielded very similar results in terms of fit and alcohol-attributable mortality as the other tested distributions.

Conclusions

Modeling alcohol consumption via the gamma distribution was feasible. To further refine this approach, research should focus on the main assumptions underlying the approach to explore differences between volume estimates derived from surveys and per capita consumption figures.

Breast Specialist Nurses – Expensive Hand Holding or Cost-Effective Counselling?

IntroductionCounselling breast cancer patients for reconstruction is complex and time consuming. Post-reconstruction satisfaction has been shown to be related to the quality of information provided to patients. Decisions regarding the type of breast reconstruction suitable for each patient is multi-factorial, including the autologous tissue available, general health, patient lifestyle and suitability, as well as patient preference. In our institution we offer a full range of reconstruction techniques. Initial pre-operative counselling is performed by a breast reconstruction specialist nurse at a consultation lasting at least 1 hour. During this time, all reconstructive options are discussed.Implications of surgery, photographs of post-operative results and the details of the procedures are explained and written information is provided. The option to meet a patient advocate at a later date is offered. An indication of the suitable reconstructive options available to the individual is given, however the surgeon, at a separate consultation lasting 10 minutes, performs the formal assessment of reconstructive type.MethodA comparison was made of patient satisfaction with pre-operative counselling and information giving, between those patients who were counselled by the operative surgeon alone and those counselled by the Breast Reconstruction Specialist nurse. A questionnaire to assess patient satisfaction with the reconstruction counselling was designed in conjunction with the Clinical Psychology team. This questionnaire was posted retrospectively to all patients who had undergone reconstruction counselling irrespective of whether they had subsequently undergone breast reconstruction. Patients were asked to respond to questions on a 5 point Likert scale. Patients were divided into 2 groups dependent on the person performing the counselling, ie. surgeon or nurse. All questionnaires were anonymous.ResultsQuestionnaires were allocated a random number and the data were analyzed independently by 2 separate clinical psychologists, blinded to which group the patients belonged to. Group 1 was counselled by the operative surgeon alone and Group 2 by the Breast Reconstruction Nurse. There was a very high response rate in both groups (70% in Group 1 and 71% in Group 2). Qualitative and quantitative data were analyzed separately. There was a high satisfaction rating in both groups with responses to all questions having a mean rating of above 4 out of 5. Patient satisfaction between the 2 groups was compared using the Mann-Whitney U test. There was no significant reported difference between how useful each of the groups found the contact.ConclusionEmploying a Specialist Nurse to perform the time-consuming pre-operative counselling for breast reconstruction is a cost effective measure, allowing Surgeons time to assess more patients or perform more appropriate skilled tasks instead. Patient satisfaction with the counselling service and information-giving was equal in both groups suggesting that nurse-led counselling, even for complex surgical procedures, is acceptable to patients. Having someone, other than the operative surgeon, give an independent and unbiased perspective on reconstructive options may be important in patient decision making.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1075.

Genetical genomic determinants of alcohol consumption in rats and humans

Background

We have used a genetical genomic approach, in conjunction with phenotypic analysis of alcohol consumption, to identify candidate genes that predispose to varying levels of alcohol intake by HXB/BXH recombinant inbred rat strains. In addition, in two populations of humans, we assessed genetic polymorphisms associated with alcohol consumption using a custom genotyping array for 1,350 single nucleotide polymorphisms (SNPs). Our goal was to ascertain whether our approach, which relies on statistical and informatics techniques, and non-human animal models of alcohol drinking behavior, could inform interpretation of genetic association studies with human populations.

Results

In the HXB/BXH recombinant inbred (RI) rats, correlation analysis of brain gene expression levels with alcohol consumption in a two-bottle choice paradigm, and filtering based on behavioral and gene expression quantitative trait locus (QTL) analyses, generated a list of candidate genes. A literature-based, functional analysis of the interactions of the products of these candidate genes defined pathways linked to presynaptic GABA release, activation of dopamine neurons, and postsynaptic GABA receptor trafficking, in brain regions including the hypothalamus, ventral tegmentum and amygdala. The analysis also implicated energy metabolism and caloric intake control as potential influences on alcohol consumption by the recombinant inbred rats. In the human populations, polymorphisms in genes associated with GABA synthesis and GABA receptors, as well as genes related to dopaminergic transmission, were associated with alcohol consumption.

Conclusion

Our results emphasize the importance of the signaling pathways identified using the non-human animal models, rather than single gene products, in identifying factors responsible for complex traits such as alcohol consumption. The results suggest cross-species similarities in pathways that influence predisposition to consume alcohol by rats and humans. The importance of a well-defined phenotype is also illustrated. Our results also suggest that different genetic factors predispose alcohol dependence versus the phenotype of alcohol consumption.

Combination immunochemotherapy followed by reduced dose (rd) whole brain radiation therapy (WBRT) in an expanded cohort of patients with newly diagnosed primary central nervous system lymphoma (PCNSL)

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Background: High-dose methotrexate (M)-based chemotherapy combined with WBRT has improved survival in patients with PCNSL. However, disease recurrence and treatment-related neurotoxicity are significant problems. We conducted a prospective trial incorporating rituximab (R) and rdWBRT and previously demonstrated this was feasible. This study was extended to assess the long-term outcome of this approach in an expanded cohort. Methods: Patients were treated with R-MPV (d1 R 500mg/m2; d2 M 3.5gm/m2; vincristine 1.4mg/m2; d1–7 procarbazine 100 mg/m2/d on odd-cycles). Patients with a PR after five cycles received two additional cycles. Patients with a CR received rdWBRT (2340cGy), otherwise patients received standard WBRT (4500cGy). Patients then received two cycles of Ara-C 3gm/m2. Prospective neuropsychological evaluations were performed at baseline, before WBRT, and every 6 months thereafter. Results: From October 2002 to September 2008, 50 patients were enrolled (22 female, 28 male), median age 59.5 years (range 30–79 years). Due to neutropenia in two of the first five patients, all subsequent patients received G-CSF. 42 patients are assessable for response (4 patients died from progressive disease prior to completing the first cycle of treatment, 4 patients - treatment ongoing). 33 patients (79%) had a CR, of whom 29 received rdWBRT (3 refused, 1 died). At median follow-up of 3 years for survivors the median OS has not been reached and the estimated 2-year OS is 68%. Patients treated with rdWBRT have a median follow up of 38 months: 21 (72%) are alive with no evidence of disease, seven (24%) relapsed, and one died of unknown causes. Eight of 21 (38%) who are alive with no evidence of disease were age 60+ at diagnosis. The number of patients treated with rdWBRT alive with no evidence of disease at 3, 4, and 5 years is 12, 8, and 4 respectively. 9 patients have completed neuropsychological evaluations 24 months after rdWBRT with no significant cognitive decline detectable. Conclusions: Prolonged follow-up of an expanded cohort of patients treated with immunochemotherapy followed by rdWBRT for patients with an initial CR continues to support our initial conclusions that this approach results in excellent disease control with no observed treatment-related neurotoxicity.

[Table: see text]

Is intimate partner violence associated with HIV infection among women in the United States?

OBJECTIVE

This study sought to examine the association between intimate partner violence (IPV) and human immunodeficiency virus (HIV) infection among a large representative sample of US women.

METHODS

Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (age, 20 years and older). The present analysis utilized the subsample of women who reported being in a relationship in the last year (n=13,928). Participants were asked whether they had experienced physical or sexual violence from their partner in the last year, as well as whether they had been diagnosed with HIV by a health care professional.

RESULTS

Past year IPV and HIV prevalence estimates among women in romantic relationships in the United States were 5.5% and 0.17%, respectively. In models adjusting for sociodemographic factors and risky sexual behaviors (e.g., age of first intercourse), IPV was significantly associated with HIV infection (adjusted odds ratios=3.44, 95% confidence interval=1.28-9.22). We also found that 11.8% of the cases of HIV infection among women were attributable to past year IPV.

CONCLUSIONS

The present study demonstrates a strong association between IPV and HIV in a representative sample of US women. Screening and prevention programs need to be aware of this important association.

DSM-IV criteria-based clinical subtypes of cannabis use disorders: results from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC)

Prior research documented high homogeneity of alcohol use disorders (AUDs) as clinical entities. However, it is unknown whether this finding extends to other substance use disorders. We investigated this by examining the prevalence of all possible DSM-IV criteria-based clinical subtypes of current and lifetime cannabis use disorders in the general population. The number of possible (i.e., theoretical) clinical subtypes of cannabis abuse and dependence based on different combinations of the DSM-IV criteria was calculated using the combinatorial function. This number was compared with the subtypes actually observed in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large U.S. national sample (N=43,093). Clinical and demographic correlates of the subtypes were examined with chi2 tests whose target population was the United States civilian non-institutionalized population. All DSM-IV cannabis abuse and dependence criteria were assessed with the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). Of all possible cannabis dependence subtypes, 29 (69%) were observed in the 12-month timeframe, and 41 (98%) in the lifetime timeframe. The corresponding numbers of subtypes for cannabis abuse were 12 (75%), current and 15 (100%), lifetime. These findings suggest that, in contrast to alcohol disorders, cannabis use disorders were highly heterogeneous. Future research should investigate whether there are differences in the course and treatment response of these clinical subtypes of cannabis use disorders, and the heterogeneity of other substance use disorders.

Assisting the transition from hospital to home for children with major congenital heart disease by telemedicine: a feasibility study and initial results

Parents of children hospitalized with major congenital heart disease often state that the weeks following discharge from hospital are particularly difficult. There is a sudden change from 24-h medical supervision and care to outpatient reviews. Videoconferencing not only gives the family an opportunity to have visual and audio contact with staff but also allows clinicians to visually assess the patient. We have investigated the feasibility of using videoconferencing to provide support for families at home. We also report the early results of a randomized control trial comparing videoconference support with regular telephone support and the current clinic review follow-up.

The latent structure of marijuana and cocaine use disorders: results from the National Longitudinal Alcohol Epidemiologic Survey (NLAES)

To better understand the underlying concepts of substance dependence and abuse, the present study examines the factor structure of DSM-IV lifetime criteria for cannabis and cocaine use disorders. Data for this study were drawn from the National Longitudinal Alcohol Epidemiologic Survey (NLAES), a large nationally representative U.S. sample aged 18 years and older. Exploratory factor analysis (EFA) examined the factor structure for each substance and the factors were related to background covariates using latent variable modeling techniques. Separate analyses were conducted for lifetime marijuana and cocaine users. A two-factor solution was identified for each substance and was similar to DSM-IV abuse and dependence. The factors were highly correlated for both cannabis (r=0.73) and cocaine (r=0.77). Background variables accounted only for a modest amount of factor variance. In conjunction with the findings in alcohol use disorders, these results support the use of consistent criteria across substances in DSM-IV and ICD-10, and suggest that the consistent finding of two correlated factors across substances needs to be better understood.

A sex-specific role of type VII adenylyl cyclase in depression

Major depression represents a complex mental disorder. The identification of biological markers that define subtypes of major depressive disorder would greatly facilitate appropriate medical treatments, as well as provide insight into etiology. Reduced activity of the cAMP signaling system has been implicated in the etiology of major depression. Previous work has shown low adenylyl cyclase activity in platelets and postmortem brain tissue of depressed individuals. Here, we investigate the role of the brain type VII isoform of adenylyl cyclase (AC7) in the manifestation of depressive symptoms in genetically modified animals, using a combination of in vivo behavioral experiments, gene expression profiling, and bioinformatics. We also completed studies with humans on the association of polymorphisms in the AC7 gene with major depressive illness (unipolar depression) based on Diagnostic and Statistical Manual of Mental Disorders IV criteria. Collectively, our results demonstrate a sex-specific influence of the AC7 gene on a heritable form of depressive illness.

Noninvasive ventilation for prevention of post-extubation respiratory failure in obese patients

Current recommendations for management of obese patients post-extubation are based on clinical experience and expert opinions. It was hypothesised that the application of noninvasive ventilation (NIV) during the first 48 h after extubation in severely obese patients would reduce post-extubation failure and avert the need for reintubation. Following protocol-driven weaning trials, 62 consecutive severely obese patients (body mass index > or =35 kg x m(-2)) were assigned to NIV via nasal mask immediately post-extubation and compared with 62 historically matched controls who were treated with conventional therapy. The primary end-point was the incidence of respiratory failure in the first 48 h post-extubation. Compared with conventional therapy, the institution of NIV resulted in 16% (95% confidence interval 2.9-29.3%) absolute risk reduction in the rate of respiratory failure. There was a significant difference in the intensive care unit and lengths of hospital stay between the two groups. Subgroup analysis of hypercapnic patients showed reduced hospital mortality in the NIV group compared with the control group. In conclusion, noninvasive ventilation may be effective in averting respiratory failure in severely obese patients when applied during the first 48 h post-extubation. In selected patients with chronic hypercarbia, early application of noninvasive ventilation may confer a survival benefit.

A randomised trial to evaluate the self-administered standardised chronic respiratory questionnaire

The original chronic respiratory questionnaire (CRQ), one of the most widely used measures of health-related quality of life (HRQL) in chronic respiratory disease (CRD), is traditionally interviewer administered (IA) and includes an individualised dyspnoea domain. The present authors studied the impact of self-administered (SA) and standardised dyspnoea questions on CRQ measurement properties. In a factorial design multicentre trial, 177 patients with CRD (mean age 67.7 yrs; mean forced expiratory volume in one second per cent predicted 44.6%) were randomised to CRQ-IA (n = 86) or CRQ-SA (n = 91), and to initially complete the standardised or individualised items before and after respiratory rehabilitation. While maintaining validity, the CRQ-SA proved more responsive to changes in HRQL than the CRQ-IA in all domains. Compared with the standardised dyspnoea domain, the individualised dyspnoea domain indicated greater responsiveness. The correlations of baseline scores and change scores with other HRQL instruments indicated good validity of the CRQ-SA. In conclusion, self-administration and standardisation of the chronic respiratory questionnaire maintains validity and responsiveness relative to the interviewer-administered chronic respiratory questionnaire. These results challenge the assumption that interviewer-administered questionnaires are superior to self-administered questionnaires in older patients with chronic respiratory disease.

Telemedicine applications for the regional paediatric cardiology service in Northern Ireland

The regional paediatric cardiology centre in Northern Ireland has a telemedicine network linking the neonatal units of three district general hospitals using ISDN and IP-compliant equipment. We have previously reported the use of ISDN transmission at 128 kbit/s for remote echocardiography. In a series of 61 patients, a total of 59 transmitted scans were of sufficient diagnostic quality to confirm or exclude the presence of major congenital heart disease (CHD). There were three diagnostic errors (7%). Subsequently, we have examined the use of ISDN transmission at 384 kbit/s. Echocardiographic studies were carried out on 21 patients and all were followed up. Fourteen patients (67%) had CHD confirmed. There were two diagnostic errors (10%). Our experience of transmitting live echocardiographic images suggests that ISDN at 384 kbit/s provides the optimum balance between the clarity of the transmitted images and costs. We expect that IP videoconferencing will offer similar quality but at a lower running cost, and are currently assessing it in a pilot study. All sites within our network will remain capable of ISDN transmission until the efficacy and reliability of IP transmission has been demonstrated in a controlled trial. The clinical telemedicine service has led to the earlier diagnosis of and instigation of appropriate treatment for CHD.

WHO/ISBRA Study on State and Trait Markers of Alcohol Use and Dependence: analysis of demographic, behavioral, physiologic, and drinking variables that contribute to dependence and seeking treatment. International Society on Biomedical Research on Alcoholism

BACKGROUND

Discussions between the World Health Organization (WHO) and the International Society on Biomedical Research on Alcoholism (ISBRA) identified the need for a multiple-center international study on state and trait markers of alcohol abuse and alcohol dependence. The reasoning behind the generation of such a project included the need to understand the alcohol use characteristics of diverse populations and the performance of biological markers of alcohol use in a variety of settings throughout the world. A second major reason for initiating this study was to collect DNA for well-structured and stratified association studies between genetic markers and/or "candidate" genes and behavioral/physiological phenotypes of importance to predisposition to alcohol dependence.

METHODS

An extensive interview instrument was developed with leadership from the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA). The instrument was translated from English to Finnish, French, German, Japanese, and Portuguese (Brazilian). One thousand eight hundred sixty-three subjects were recruited at five clinical centers (Montreal, Canada; Helsinki, Finland; Sapporo, Japan; São Paulo, Brazil; and Sydney, Australia). The subjects responded to the structured interview and provided blood and urine samples for biochemical analysis. This article focuses on the demographic characteristics of the study subjects, their drinking habits, alcohol-dependence characteristics, comorbid psychiatric and other drug variables, and predictors for seeking treatment for alcohol dependence. Multiple logistic regression models were constructed and used to explore variables that contribute to various levels of alcohol consumption, to a diagnosis of alcohol dependence, and to seeking treatment for alcohol dependence. ANOVA with post hoc comparisons, chi2, and Pearson moment calculations were used as necessary to assess additional relationships between variables.

RESULTS

A number of factors previously noted in disparate studies were confirmed in our analysis. Men consumed more alcohol than women, Asians consumed less alcohol than whites or Blacks, alcohol-dependent subjects consumed more alcohol than nondependent subjects, alcohol consumption increased with age, and an increased level of education (university or postgraduate education) reduced the percentage of such individuals in the category designated as heavy drinkers (>210 g alcohol/week) and in the group who were currently in treatment for dependence. However, our analysis allowed for much more detailed comparisons; for example, although men drank more than women on a g/day basis, the differences were less pronounced on g/kg/day basis, and alcohol-dependent women drank equal amounts of alcohol as alcohol-dependent men on a g/kg/day basis. Antisocial personality characteristics or reports of trouble sleeping when an individual stops drinking were associated with higher alcohol intake. The most important of the tested factors that contributed to a DSM-IV diagnosis of dependence, however, was the report of anxiety if an individual stopped drinking. In terms of the various criteria within the DSM-IV criteria for alcohol dependence, no one criterion seemed to be prominent for individuals who sought alcohol dependence treatment, but the higher the number of criteria met by the individual, the higher was the probability that he or she would be in treatment.

CONCLUSIONS

This initial report is the beginning of the "data mining" of this rich data set. The cross-national/cross-cultural aspects of this study allowed for multiple comparisons of variables across several ethnic/racial groups and allowed for assessment of biochemical markers for alcohol intake and predisposition to alcohol dependence in diverse settings.