Development and Initial Pilot Testing of a fully integrated treatment for comorbid social anxiety disorder and alcohol use disorder in a community-based SUD clinic setting

OBJECTIVES

Social anxiety disorder (SAD) and alcohol use disorder (AUD) are highly comorbid and this comorbidity is associated with poorer clinical outcomes. Integrating exposure-based treatment for SAD into the context of typical AUD treatment programs should improve engagement and treatment outcomes for this population.

METHODS

After initial development of a fully integrated, intensive outpatient program (IOP) for individuals with comorbid SAD and AUD, patients with SAD and AUD were recruited from a community-based SUD specialty clinic (N = 56) and randomized to either (a) usual care (UC), consisting of the evidence-based Matrix Model of Addiction IOP; or (b) the Fully Integrated Treatment (FIT) for comorbid SAD and AUD IOP. Participants were assessed on indices of social anxiety and alcohol use.

RESULTS

By the 6-month follow-up, those in FIT showed superior improvement to UC on number of drinking days in the past 30 days and social anxiety severity at follow-up, but there were no differences between groups on quantity of alcohol consumed on drinking days. Alcohol-related problems improved in both groups, with no statistically significant differences. Within-group improvement was observed in FIT (but not in UC) on drinking to cope with social anxiety and avoidance of social situations without alcohol, but between-group effects were non-significant. In sum, the integrated treatment of SAD and AUD led to greater reductions in both the frequency of drinking and in social anxiety symptoms than usual care.

CONCLUSIONS

Targeting social anxiety in the context of AUD treatment is a promising approach to improving the treatment of this common comorbidity.

Behavioral Economic Demand for Alcohol and Cigarettes in Heavy Drinking Smokers: Evidence of Asymmetric Cross-commodity Reinforcing Value

INTRODUCTION

Previous studies have highlighted a strong bidirectional relationship between cigarette and alcohol consumption. To advance our understanding of this relationship the present study uses a behavioral economic approach in a community sample (N = 383) of nontreatment seeking heavy drinking smokers.

AIMS AND METHODS

The aims were to examine same-substance and cross-substance relationships between alcohol and cigarette use, and latent factors of demand. A community sample of nontreatment seeking heavy drinking smokers completed an in-person assessment battery including measures of alcohol and tobacco use as well as the Cigarette Purchase Task and the Alcohol Purchase Task. Latent factors of demand were derived from these hypothetical purchase tasks.

RESULTS

Results revealed a positive correlation between paired alcohol and cigarette demand indices (eg, correlation between alcohol intensity and cigarette intensity) (rs = 0.18-0.46, p ≤ .003). Over and above alcohol factors, cigarette use variables (eg, Fagerström Test for Nicotine Dependence and cigarettes per smoking day) significantly predicted an additional 4.5% (p < .01) of the variance in Persistence values but not Amplitude values for alcohol. Over and above cigarette factors, alcohol use variables predicted cigarette Persistence values (ΔR2 = .013, p = .05), however, did not predict Amplitude values.

CONCLUSIONS

These results advance our understanding of the overlap between cigarette and alcohol by demonstrating that involvement with one substance was associated with demand for the other substance. This asymmetric profile-from smoking to alcohol demand, but not vice versa-suggests that it is not simply tapping into a generally higher reward sensitivity and warrants further investigation.

IMPLICATIONS

To our knowledge, no study to date has examined alcohol and cigarette demand, via hypothetical purchase tasks, in a clinical sample of heavy drinking smokers. This study demonstrates that behavioral economic indices may be sensitive to cross-substance relationships and specifically that such relationships are asymmetrically stronger for smoking variables affecting alcohol demand, not the other way around.

Reliability and Validity of an Observational Measure of Client Decision-Making: The Client Language Assessment - Proximal/Distal (CLA-PD)

OVERVIEW

The Client Language Assessment - Proximal/Distal (CLA-PD) is a language rating system for measuring client decision-making in interventions that target a specified behavior change (e.g., alcohol or other drug use). In the CLA-PD, there are five dimensions of change language (Reason, Ability, Commitment, Taking Steps, Other) adapted from the client portion of the Motivational Interviewing Skill Code (MISC). For the CLA-PD, language codes are sub-divided to discriminate statements regarding the primary, or target behavior change (distal change) from the intermediate coping activities (proximal change) that are prescribed to facilitate that target behavior change. The goal of the CLA-PD is to allow for higher specificity than existing client language measures, when process studies consider interventions that are multi-session and skill-based (e.g., cognitive behavioral therapy).

METHOD

Three raters received 40 hours of training on the use of the CLA-PD. The data were a sample of therapy session audio-files from a completed clinical trial (N=126), which enabled examination of client language across four sessions (i.e., first three and final attended) of three evidence-based alcohol interventions (cognitive behavioral therapy, twelve-step facilitation therapy, motivational enhancement therapy).

RESULTS

Inter-rater reliability results for summary scores showed "excellent" reliability for the measure. Specifically, two-way mixed intraclass coefficients ranged from .83 to .95. Internal consistency reliability showed alphas across sessions that ranged from "fair" to "good" (α=.74-.84). In convergent and discriminant validity analyses using data independently measured with MISC-based ratings, the pattern of results was as would be expected. Specifically, convergent correlations, by valence (i.e., change and sustain talk), between CLA-PD Distal and MISC-based language scores were moderate (r=.46-.55, p<.001) while discriminant correlations by valence for CLA-PD Proximal and MISC-based language scores were small (r=.22-.24, p<.05). Finally, proportion Change Talk Proximal predicted subsequent session coping behaviors (i.e., processes of change) as well as 3-month Alcoholics Anonymous involvement and attendance (ps<.05-.005), but not 3-month alcohol abstinence self-efficacy. Further, analyses of criterion predictive validity showed that proportion Change Talk Distal predicted 3- and 12-month drinking frequency and quantity measures (ps<.05-.005).

CONCLUSIONS

When behavior change treatments are multi-session and/or skill-based, the present analyses suggest the CLA-PD is a promising, psychometrically sound observational rating measure of client verbalized decision-making.

Determinants of problem drinking and depression among Latino Day laborers

Little is known about alcohol misuse and depression among Latino day laborers despite the fact that they encounter multiple stressors (e.g., job instability, unsafe work environments). A structural equation model tested the relationships among laborer stress, social support, health status, current alcohol misuse, and depression. A sample of 89 male, urban Latino day laborers completed measures assessing these constructs in 2011. Stress was negatively related to physical health status, which was associated with depression. Findings suggest that stressors specific to being a day laborer resulting from their work and living conditions generate and maintain health disparities in this vulnerable population.

Patient reactance moderates the effect of directive telephone counseling for methamphetamine users

OBJECTIVE

This study examined the impact of the interaction between patient reactance and treatment directiveness on the effectiveness of telephone aftercare for methamphetamine dependence.

METHOD

Reactance was assessed at baseline, and participants were randomly assigned to directive or nondirective treatment conditions. Logistic regression tested for the significance of the interaction as a predictor of 3-month and 12-month use of methamphetamine and stimulants.

RESULTS

A significant interaction was observed at the 3-month follow-up, in which the directive condition was less effective for patients higher in reactance and was more effective for patients lower in reactance. Among patients at a high level of reactance, the nondirective condition increased the likelihood of abstinence.

CONCLUSIONS

This study suggests that, in the context of telephone-based care, directive interventions offer short-term clinical benefit for methamphetamine users who readily accept influence from authority figures, whereas nondirective interventions offer benefit for patients who do not readily accept influence. The short-term nature of these effects indicates that there is a need for brief but ongoing telephone support to maintain treatment gains.

A comparison of four telephone-based counseling styles for recovering stimulant users

The continuing development and refinement of empirically supported interventions to increase participation in posttreatment care and promote sustained abstinence from illicit drug use is a priority for the addictions field. The purpose of this study was to assess the combined and relative effectiveness of four types of counseling styles, delivered by telephone, relative to a no call control condition. Stimulant users (N = 302) were randomized to one of four low-cost, telephone support protocols (unstructured/nondirective, unstructured/directive, structured/nondirective, structured/directive) or a standard referral to aftercare without telephone counseling (control). All of the study participants were nearing the completion of (or had completed) an intensive phase of structured, outpatient stimulant abuse treatment. Drug use and aftercare participation were assessed at 3 and 12 months following randomization. Intent-to-treat analyses showed no significant time-by-group interactions for these primary outcomes. Subsequent analyses, however, revealed a significant difference between the aggregated call groups and the control group at the time of the 3-month follow-up. The mean ASI drug use severity composite score for subjects in the call conditions declining from .058 at baseline to .048 at 3 months, whereas the no call/control group average score increased from .053 to .062 (χ (1) = 4.95, p = .026). A similar-and slightly stronger-effect was found when the study sample was restricted to those reporting any use during the month prior to the baseline interview (n = 152). This study provides modest support for the telephone-based counseling approaches strategies examined in this project. Subsequent research will assess interactions between patient characteristics and counseling styles, and improved identification of which treatment graduates might be more likely to benefit from this type of continuing support. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

Factor structure of the Alcohol Use Disorders Identification Test (AUDIT) in a mental health clinic sample

OBJECTIVE

To examine the factor structure of the Alcohol Use Disorders Identification Test (AUDIT) and to identify the implications of this structure for its clinical use.

METHOD

The AUDIT was administered to mental health clinic outpatients (N = 197; 86% men) at high risk for alcohol-use disorders. Confirmatory and exploratory factor analyses were used to determine the underlying factor structure of the AUDIT for this high-risk population.

RESULTS

Confirmatory analyses indicated that the a priori three- and one-factor solutions did not fit the observed data. The exploratory analyses supported a two-factor solution that included level of alcohol consumption and drinking problems, with both factors explaining substantial variance in AUDIT scores. These findings contrast the original three-factor design of the AUDIT and the conventional use of the AUDIT as a one-factor screening device with a single cutoff score.

CONCLUSIONS

Other screening methods that incorporate this two-factor model may be important for mental health patient populations. Replication of these findings among other mental health samples is needed.

Immigrant families coping with schizophrenia. Behavioral family intervention v. case management with a low-income Spanish-speaking population

BACKGROUND

This investigation compared the effectiveness and cross-cultural applicability of behavioural family management (BFM) and standard case management in preventing exacerbation of symptoms and relapse in schizophrenia.

METHOD

Forty low-income Spanish-speaking people with a diagnosis of schizophrenia were randomly assigned to receive standard case management or behavioural family management after stabilisation with neuroleptic medication.

RESULTS

Survival analyses indicated that among the less acculturated patients BFM was significantly related to greater risk of exacerbation of symptoms. Among the more acculturated patients, risk of exacerbation could be predicted by medication compliance but not by type of intervention. In analyses of symptom severity and functional status at 1-year follow-up, the level of patient acculturation was found to be significantly related to various measures of treatment outcome.

CONCLUSION

Sociocultural factors affect responses to different types of intervention. The results did not support earlier findings of a beneficial effect of BFM when applied to a socioculturally diverse population.

An attributional analysis of expressed emotion in Mexican-American families with schizophrenia

In this study we tested an attributional model of expressed emotion (EE) among Mexican-American families. A sample of 46 key family members of schizophrenic patients were measured on three dimensions: affect toward patient, controllability attributions, and level of EE. Consistent with an attributional model, we found that high EE families (defined on the basis of critical comments) viewed the illness and associated symptoms as residing within the patient's personal control, more so than did low EE families. We also found that attributions held by family members are related to their affective reactions. Specifically, family members who perceived the patient as having control over the symptoms of schizophrenia tended to express greater negative emotions such as anger and annoyance toward the patient than did family members who viewed the symptoms as beyond the patient's personal control. An examination of the types of affects found and their relationship to EE status is discussed, along with implications for this research.

An attributional analysis of expressed emotion in Mexican-American families with schizophrenia

In this study we tested an attributional model of expressed emotion (EE) among Mexican-American families. A sample of 46 key family members of schizophrenic patients were measured on three dimensions: affect toward patient, controllability attributions, and level of EE. Consistent with an attributional model, we found that high EE families (defined on the basis of critical comments) viewed the illness and associated symptoms as residing within the patient's personal control, more so than did low EE families. We also found that attributions held by family members are related to their affective reactions. Specifically, family members who perceived the patient as having control over the symptoms of schizophrenia tended to express greater negative emotions such as anger and annoyance toward the patient than did family members who viewed the symptoms as beyond the patient's personal control. An examination of the types of affects found and their relationship to EE status is discussed, along with implications for this research.

One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the Epidemiologic Catchment Area study

The associations between the one-month prevalence rates of mental disorders and sociodemographic characteristics were investigated for 18,571 people interviewed in the first-wave community samples of all 5 sites in the US National Institute of Mental Health (NIMH) Epidemiologic Catchment Area program. Men were found to have a significantly higher rate of cognitive impairment than women after controlling for the effects of age, race or ethnicity, marital status and socioeconomic status. Marital status was one of the most powerful correlates of mental disorder risk: the odds of separated or divorced people having any NIMH Diagnostic Interview Schedule disorder were twice that of married people after controlling for age, gender, race or ethnicity and socioeconomic status. The odds of those in the lowest socioeconomic status group having any Diagnostic Interview Schedule disorder was about 2.5 times that of those in the highest socioeconomic status group, controlling for age, gender, race or ethnicity and marital status. For all disorders except cognitive impairment, race or ethnicity did not remain statistically significant after controlling for age, gender, marital status and socioeconomic status.

Cross-cultural issues in the course and treatment of schizophrenia

In conclusion, we strongly share the belief recently expressed by Lefley that "the dialogue on clinical and social implications of research on expressed emotion may play a positive role" in the provision of care through a mental health service system that enlists, supports, and trains diverse intra and extra-familial caregivers in the many therapeutic tasks required for the care of the person and family afflicted with schizophrenia. We regard such a prescription as applicable in all social and cultural contexts.

The meaning of expressed emotion: theoretical issues raised by cross-cultural research

The finding that expressed emotion is associated with the course of psychiatric disorder has generated a great deal of clinical and research interest in expressed emotion as an important risk factor. Theoretical elucidation of the construct of expressed emotion has lagged considerably behind this interest, however. The authors contribute to a dialogue on what is inside the "black box" called expressed emotion. They argue that cross-cultural research can provide an empirical basis for the theoretical grounding of expressed emotion factors. A comparative approach reveals that the construct of expressed emotion is essentially cultural in nature. The constellation of emotions, attitudes, and behaviors that are indexed by the expressed emotion method represent cross-culturally variable features of family response to an ill relative. Questions surrounding the cultural validity of the construct of expressed emotion, the qualitative dimensions of expressed emotion, and statistically significant cross-cultural variations in expressed emotion profiles are discussed. Finally, the authors provide an outline of diverse (cultural, psychobiological, social-ecological) features of expressed emotion. Anthropological analysis of expressed emotion reveals that although expressed emotion indexes a Pandora's box of diverse features, culture provides the context of variation through which these factors are most productively analyzed.

Symptoms of major depression among Mexican-Americans and non-Hispanic whites

The lifetime prevalence of symptoms of a major depressive episode was estimated in two large samples of randomly selected community residents that included many Mexican-Americans. Approximately 5% to 40% of the subjects reported each symptom cluster. The rates for Mexican-Americans born in the United States resembled those for non-Hispanic whites born in the United States; however, the rates for Mexican-Americans born in Mexico were lower in eight of nine symptoms clusters. Language differences did not account for this pattern. Cultural similarity to non-Hispanic whites born in the United States was associated with a higher rate of depressive symptoms.

Parental communication deviance and schizophrenia: a cross-cultural comparison of Mexican- and Anglo-Americans

Levels of parental communication deviance (CD), as measured on the Thematic Apperception Test (TAT), were compared among families of schizophrenic patients in two culturally distinct groups. Spanish-speaking Mexican-American parents of schizophrenics completed the TAT in their native language, and CD was coded from their stories by a Spanish-speaking rater. Mexican-American parents had levels of CD that were nearly identical to those of a carefully matched sample of English-speaking Anglo-American parents. Factor scores that measure distinct subtypes of CD also did not differ across groups. The data suggest that levels of CD, despite discriminating between parents of schizophrenics and nonschizophrenics, do not vary across different languages and cultures.

Teaching transcultural psychiatry

The ethnic diversity of patients in most training centers requires that attention be given to cultural issues affecting the psychiatric presentation and treatment of patients from different backgrounds. This paper describes programs in transcultural psychiatry for medical students, residents, and fellows that have been implemented and refined at UCLA over the past six years. Suggestions are offered for the development of such programs elsewhere.

Acculturation and the probability of use of health services by Mexican Americans

How does level of acculturation affect the probability that Mexican Americans use general health, mental health, and human social services? We studied this question using data from a general population sample of Mexican Americans (N = 1,055). Data were elicited in face-to-face interviews. After controlling for sociodemographic and economic factors, health status, and insurance coverage, Mexican Americans who were less acculturated had significantly lower probabilities of an outpatient medical visit for physical health problems and of a visit to a mental health specialist or human service provider for emotional problems. The less acculturated with good perceived general health were especially unlikely to receive outpatient medical care. Having Medicaid coverage was associated with a larger increase in the probability of an inpatient medical admission for the more acculturated than for the less acculturated. Other individual characteristics had generally similar effects on use of medical and mental health services for both the more and the less acculturated Mexican Americans.

Anxiety disorders among Mexican Americans and non-Hispanic whites in Los Angeles

This report from the Los Angeles site of the NIMH Epidemiologic Catchment Area study reveals significant ethnic and national origin differences in lifetime prevalence rates for three out of six specific, DSM-III-defined anxiety disorders. In the case of simple phobia, United States-born Mexican Americans report higher rates than native non-Hispanic whites or immigrant Mexican Americans, the latter two groups having similar rates. Mexican Americans born in the United States had higher rates of agoraphobia than immigrant Mexican Americans, and non-Hispanic whites reported higher lifetime rates of generalized anxiety disorder compared with both immigrant and native Mexican Americans. Neither ethnic nor national origin differences in lifetime prevalence rates were found for panic disorder, social phobia, and obsessive-compulsive disorder. Selective migration is postulated as a potential factor influencing prevalence differences between native and immigrant Mexican Americans.

Somatic symptom index (SSI): a new and abridged somatization construct. Prevalence and epidemiological correlates in two large community samples

An abridged somatization construct (the Somatic Symptom Index) derived from the Diagnostic Interview Schedule's somatization disorder items was tested on community epidemiological samples to examine its prevalence, risk factors, and predictive value. The construct had a high prevalence (range, 4.4% to 20% compared with .03% to 0.7% for the full DSM-III somatization disorder diagnosis), was related to low socioeconomic status, female gender, older chronological age, and Hispanic ethnic background. The presence of this construct determined preferential use of medical services and predicted high indices of disability. The Somatic Symptom Index may have practical utility for clinical and community studies of somatoform phenomena.

Parental communication deviance and schizophrenia: A cross-cultural comparison of Mexican- and Anglo-Americans

Levels of parental communication deviance (CD), as measured on the Thematic Apperception Test (TAT), were compared among families of schizophrenic patients in two culturally distinct groups. Spanish-speaking Mexican-American parents of schizophrenics completed the TAT in their native language, and CD was coded from their stories by a Spanish-speaking rater. Mexican-American parents had levels of CD that were nearly identical to those of a carefully matched sample of English-speaking Anglo-American parents. Factor scores that measure distinct subtypes of CD also did not differ across groups. The data suggest that levels of CD, despite discriminating between parents of schizophrenics and nonschizophrenics, do not vary across different languages and cultures.

The epidemiology of obsessive-compulsive disorder in five US communities

The prevalence of obsessive-compulsive disorder was measured in five US communities among more than 18,500 persons in residential settings as part of the National Institute of Mental Health (Bethesda, Md)--sponsored Epidemiologic Catchment Area program. Lifetime prevalence rates ranged from 1.9% to 3.3% across the five Epidemiologic Catchment Area sites for obsessive-compulsive disorder diagnosed without DSM-III exclusions and 1.2% to 2.4% with such exclusions. These rates are about 25 to 60 times greater than had been estimated on the basis of previous studies of clinical populations.

One-month prevalence of mental disorders in the United States. Based on five Epidemiologic Catchment Area sites

One-month prevalence results were determined from 18,571 persons interviewed in the first-wave community samples of all five sites that constituted the National Institute of Mental Health Epidemiologic Catchment Area Program. US population estimates, based on combined site data, were that 15.4% of the population 18 years of age and over fulfilled criteria for at least one alcohol, drug abuse, or other mental disorder during the period one month before interview. Higher prevalence rates of most mental disorders were found among younger people (less than age 45 years), with the exception of severe cognitive impairments. Men had higher rates of substance abuse and antisocial personality, whereas women had higher rates of affective, anxiety, and somatization disorders. When restricted to the diagnostic categories covered in international studies based on the Present State Examination, results fell within the range reported for European and Australian studies.

Distribution of major mental disorders in an US metropolis

This paper reviews the evolution of psychiatric nosologies in North America and the major epidemiological surveys of Mental Disorders culminating with the recently completed National Institute of Mental Health Epidemiologic Catchment Area project (NIMH-ECA). The NIMH-ECA examined the prevalence of diagnosable (DSM III) Mental disorders in 5 U.S. communities utilizing a highly structured diagnostic interview, the Diagnostic Interview Schedule (DIS). Data from the Los Angeles ECA, one of five study sites are presented with particular emphasis on cross-cultural comparison (Mexican Americans versus Non Hispanic Whites). Overall, there were only a few cross-cultural differences in prevalence of specific diagnoses. Mexico-born Mexican Americans showed a lower prevalence for most disorders examined than their U.S. born counterparts, and a subgroup of Mexican-American women (those over the age of 40) showed higher rates of phobic and dysthymic disorders as well as a greater number of functional somatic symptoms than other groups.

Factors affecting the probability of use of general and medical health and social/community services for Mexican Americans and non-Hispanic whites

Are individual characteristics associated with use of general and mental health and human service sectors similar for Mexican Americans (MAs) and non-Hispanic whites (NHWs)? We addressed this question using data from the Los Angeles site of the NIMH Epidemiologic Catchment Area Program. A random sample of the general population of two mental health catchment areas was interviewed in 1983-1984. With four exceptions, individual variation in sociodemographic factors, insurance coverage, and health status had similar effects on the probability of use of the general and mental health and human service sector for both NHWs and MAs. Recent psychiatric disorder was associated with greater use of general medical providers for mental health care for both NHWs and MAs, but significantly more so for NHWs. Female NHWs were more likely to use the human service sector (e.g., social service agencies) than male NHWs, but gender had no effect on this type of use for MAs. Higher job status was associated with greater use of outpatient general medical services, but significantly more so for NHWs than MAs. By contrast, having private health insurance was associated with a greater increase in use of outpatient general medical services for MAs than for NHWs.

Affective disorders in five United States communities

Results on the age/sex specific prevalence of DSM-III affective disorders from the NIMH Epidemiologic Catchment Area Study (ECA), a probability sample of over 18,000 adults from five United States communities, are presented. The cross-site means for bipolar disorder ranged from 0.7/100 (2 weeks) to 1.2/100 (lifetime), with a mean age of onset of 21 years and no sex difference in rates. The cross-site means for major depression ranged from 1.5/100 (2 weeks) to 4.4/100 (lifetime), with a mean age onset of 27 years and higher rates in women. The cross-site means for dysthymia, a chronic condition, was 3.1/100 with a higher rate in women. There was reasonable consistency in prevalence rates among sites. The implications of these findings for understanding psychopathology are discussed.

Lifetime prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles

The lifetime prevalence of specific DSM-III-defined psychiatric disorders among 1243 Mexican-American and 1309 non-Hispanic white residents of two Los Angeles communities is reported from the Los Angeles site of the Epidemiologic Catchment Area (ECA) research study. Results from household interviews in response to the National Institute of Mental Health Diagnostic Interview Schedule revealed overall rates of disorders for the total Los Angeles sample and ethnic subsamples that were similar to rates reported from the initial three ECA sites. Non-Hispanic whites reported far more drug abuse/dependence and more major depressive episodes than Mexican Americans. Young non-Hispanic white women reported high rates of major depressive episodes and drug abuse/dependence. Alcohol abuse/dependence is highly prevalent among Mexican-American and non-Hispanic white men of any age. Mexican-American women infrequently abuse or become dependent on drugs or alcohol at any age. Dysthymia, panic disorder, and phobia are somewhat more prevalent among Mexican-American women over 40 years of age compared with both non-Hispanic white women over and Mexican-American women under 40 years of age. Antisocial personality is predominantly a disorder of young men of both ethnic groups.

Somatization in the community

We examined the prevalence of somatization disorder symptoms elicited with the Diagnostic Interview Schedule in 3132 community respondents interviewed in Los Angeles by the Epidemiologic Catchment Area program. The variables age, gender, ethnic background, and the presence of a psychiatric diagnosis significantly influenced the number of somatization symptoms reported. An introductory review on conceptual and nosological aspects of somatization phenomena led to the formulation of a less-restrictive operational definition of the somatizer. We found that 4.4% of the respondents met criteria for this abridged cutoff score of somatization, whereas only 0.03% of the respondents met criteria for the full DSM-III somatization disorder diagnosis. This abridged cutoff score was associated with sociodemographic factors and psychiatric diagnosis in the direction predicted.

Six-month prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles

The current prevalence of DSM-III psychiatric disorders was assessed using the Diagnostic Interview Schedule (DIS) as part of a Los Angeles household population survey. The Los Angeles prevalence estimates were compared with sex- and age-adjusted estimates from four other US field sites, all of which were part of the Epidemiologic Catchment Area (ECA) program. Overall, few significant differences in household population rates were found between Los Angeles and the other ECA sites. Within the Los Angeles household sample, the current prevalence of disorder among Mexican Americans was compared with that among non-Hispanic whites. Non-Hispanic whites had higher rates of drug abuse/dependence than Mexican Americans; the rates among non-Hispanic whites in Los Angeles were also higher than those found at other ECA sites. Mexican Americans displayed higher rates of severe cognitive impairment, a finding that likely reflects ethnic and educational bias in the measurement of cognitive impairment. Another ethnic difference was found only for one specific age and sex group: Mexican-American women 40 years of age or older had strikingly high rates of phobia.

Utilization of health and mental health services by Los Angeles Mexican Americans and non-Hispanic whites

Utilization of general medical and mental health services by respondents in the Los Angeles Epidemiologic Catchment Area (ECA) site was compared with that in three ECA sites studied previously (New Haven, Conn, Baltimore, and St Louis). Within the Los Angeles sample, Mexican-American patterns of utilization were compared with those for non-Hispanic whites. Los Angeles respondents were less likely than those at other ECA sites to make ambulatory health care visits and to be hospitalized for physical or mental health reasons. Mexican Americans were less likely than non-Hispanic whites to report ambulatory health care but were as likely to have been hospitalized. Six percent of Los Angeles respondents reported a recent mental-health-care visit as compared with 6% to 7% of respondents at the other ECA sites. However, among respondents with Diagnostic Interview Schedule DSM-III disorders diagnosed within the six months prior to the interview, a lower proportion made a mental health visit in Los Angeles (14%) compared with the other sites (16% to 20%). Of those who made a mental-health-care visit, Los Angeles respondents with a recently diagnosed disorder were more likely than comparable respondents at the other ECA sites to visit a mental health specialist rather than a general medical care provider. Mexican Americans with a recently diagnosed mental disorder were only half as likely as non-Hispanic whites (11% vs 22%, respectively) to have made a mental health visit. However, when Mexican Americans with Diagnostic Interview Schedule/DSM-III did make a mental health visit, they were as likely as non-Hispanic whites to see a mental health specialist.

Which Mexican-Americans underutilize health services?

Data collected from the Los Angeles site of the National Institute of Mental Health Epidemiologic Catchment Area Program were used to examine the utilization of health services in a community population. Mexican-Americans, especially the less acculturated, had significantly lower rates of use of outpatient, but not inpatient, care than non-Hispanic whites. Differences were greater for mental than physical health care. Less acculturated Mexican-Americans made very little use of either mental health specialists or the human services sector (e.g., religious leaders). Among those with a recent psychiatric disorder, non-Hispanic whites were seven times more likely to use outpatient mental health services than the less acculturated Mexican-Americans.

Somatization in the community: relationship to disability and use of services

We tested the hypotheses that an abridged somatization construct that we had developed would be associated with use of health services, preferential use of medical over mental health services, and an index of disability. These hypotheses were tested using structured interview data from 3,132 randomly selected community respondents. We found that: respondents meeting criteria for somatization reported a heavier use of health services than non-somatizers; of those respondents meeting criteria for a psychiatric diagnosis, somatizers preferentially used medical over mental health services whereas non-somatizers reported the opposite trend; and somatizers were more likely than non-somatizers to report recent sick leave or restricted activity.

Expressed emotion and schizophrenic outcome among Mexican-American families

This study has demonstrated that among low-income, relatively unacculturated Mexican-American households, a high level of expressed emotion on the part of key relatives significantly increases the risk of relapse for remitted schizophrenics who return home to live with their families after hospital discharge. This cross-cultural replication of earlier research findings in London and southern California suggests that critical, hostile, or emotionally overinvolved attitudes and behaviors may be general major stressors that adversely influence the fragile adaptation of schizophrenic individuals in diverse cultural settings. The finding of a lower prevalence of high levels of expressed emotion among Mexican-American compared to Anglo-American and British households lends support to the hypothesis that intrafamilial behaviors may account for different schizophrenic outcomes in different cultures.

Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts

The Mini-Mental State Evaluation (MMSE) was used in an epidemiological survey of a community of mixed ethnicity (Hispanic, white non-Hispanic) as part of the Los Angeles Epidemiologic Catchment Area Program. Results of the study showed that age, educational level, ethnicity, and language of the interview influenced the number of MMSE errors. Items on which the effects of ethnicity and language were most pronounced were identified, and suggestions on ways to minimize such sociocultural artifacts are provided in efforts to improve the epidemiological significance of the instrument, particularly as it concerns cross-cultural research.

A brief method for assessing expressed emotion in relatives of psychiatric patients

A measure of the attitudes and feelings that a relative expresses about a mentally ill family member, termed expressed emotion (EE), is derived from an extensive, semistructured interview, the Camberwell Family Interview (CFI). The present article describes a method for the assessment of EE attitudes that uses a variation of the 5-minute speech sample, originally developed by Gottschalk and Gleser (1969). The measure is derived from responses made by a patient's key relative when prompted to give thoughts and feelings about the patient for a 5-minute period. A coding system was developed to score behaviors analogous to those rated on the CFI, such as criticism and emotional overinvolvement. The relationship between blind EE ratings derived from the 5-minute speech samples and those from the CFI was investigated with two separate samples of relatives of schizophrenics. The relationship between the sets of ratings was very close and supports the value of the 5-minute speech sample as a brief EE screening procedure.

The NIMH-DIS in the assessment of DSM-III schizophrenic disorder

The National Institute of Mental Health Diagnostic Interview Schedule (NIMH-DIS) was administered by trained lay interviewers to a sample of 82 outpatients with clinical diagnoses of DSM-III schizophrenic disorder. Of these subjects, 77 percent were also diagnosed as suffering from DSM-III schizophrenic disorder according to the structured interview (NIMH-DIS) administered by a lay interviewer. The DIS interviews were scrutinized to find the reasons for their discrepancy with the clinical diagnoses. A majority of the DIS-negative schizophrenic subjects acknowledged significant psychopathology in the DIS and missed only one of the six DSM-III criteria items for schizophrenia. Test-retest results showed consistency in the subjects' reporting of lifetime schizophrenic symptoms.

The mental health needs of Mexican-American agricultural workers

We used three measurement procedures to produce a comprehensive profile of the mental health needs of Mexican-American farmworkers and to determine what kinds of mental health services were required to meet those needs. These measurement procedures were a field survey, a key informant survey, and a nominal group process. The results of the field survey indicated that rural Mexican Americans are not being served by mental health providers, despite their having higher symptom levels than would be expected in the general population and their substantial use of rural primary health clinics and private physicians. The key informant survey included mental health providers, health providers, and community agency personnel. According to these informants, the mental health sector is unable to provide services for the farmworkers; and the ability of other providers to reach them depends on a number of factors, including the nature of the services offered and the socioeconomic characteristics of the farmworkers themselves. Key informants identified the environmental conditions implicated in the farmworkers' psychosocial problems and recommended types of services, sites, and key personnel. Key informants concurred that general health settings and multiservice agencies were the most appropriate for reaching Mexican Americans, and that mental health services must include bilingual and bicultural staff members. Key informants disagreed, however, about the relative value of certain kinds of mental health services. The nominal group process identified 32 design criteria that could be used to improve mental health services for farmworkers.(ABSTRACT TRUNCATED AT 250 WORDS)

Exclusion criteria of DSM-III. A study of co-occurrence of hierarchy-free syndromes

The diagnostic criteria of the third edition of the DSM-III often state that one diagnosis cannot be made if it is "due to" another disorder. Using data from the National Institute of Mental Health Diagnostic Interview Schedule, with a sample of 11,519 subjects from a community population, we found that if two disorders were related to each other according to the DSM-III exclusion criteria, then the presence of a dominant disorder greatly increased the odds of having the excluded disorder. We also found that disorders, which DSM-III says are related to each other, were more strongly associated than disorders, which DSM-III says are unrelated. However, we also found there was a general tendency toward co-occurrence, so that the presence of any disorder increased the odds of having almost any other disorder, even if DSM-III does not list it as a related disorder. We concluded that empirical studies are needed to study the assumptions underlying the use of a diagnostic hierarchy.

The Spanish Diagnostic Interview Schedule. Reliability and comparison with clinical diagnoses

The National Institute of Mental Health Diagnostic Interview Schedule (DIS) was translated into Spanish. The reliability of the Spanish instrument, its equivalence to the English version, and its agreement with clinical diagnoses were examined in a study of 90 bilingual (English-and Spanish-speaking) and 61 monolingual (Spanish-speaking only) patients from a community mental health center. The study design involved two independent DIS administrations and one independent clinical evaluation of each subject.

Development of the Spanish-language version of the National Institute of Mental Health Diagnostic Interview Schedule

The use of the National Institute of Mental Health Diagnostic Interview Schedule (DIS) to elicit DSM-III-defined mental disorders among Hispanic respondents in the Los Angeles site of the Epidemiologic Catchment Area project required development of a Spanish translation of the instrument that would be understood readily by persons of Mexican, Puerto Rican, and Cuban origin. The translation was carried out using back translation, bilingual test respondents, a bilingual translation staff, an extensive committee of experienced bilingual clinicians as translation consultants, and revision following clinical evaluation. A study of its reliability and comparison with clinical diagnoses obtained with Spanish-speaking psychiatric outpatients indicated satisfactory equivalence of the Spanish DIS to the English version. Early international use of the Spanish DIS promises new data on the cross-cultural validity and prevalence rates of DSM-III-diagnosed disorders.