Psychiatric disorders and risk for multiple adverse outcomes: a national prospective study.

Most psychiatric disorders, when examined individually, are associated with a broad range of adverse outcomes. However, psychiatric disorders often co-occur and their co-occurrence is well explained by a limited number of transdiagnostic factors. Yet it remains unclear whether the risk of these adverse outcomes is due to specific psychiatric disorders, specific dimensions of psychopathology (i.e., internalizing and externalizing dimensions), a general psychopathology factor, or a combination of these explanations. In a large nationally representative prospective survey, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), we used structural equation modeling to examine the shared and specific effects of common Axis I and Axis II disorders on the risk of ten adverse outcomes (unemployment; financial crisis; low income; poorer general health; worse mental and physical health; legal problems; divorce; problems with a neighbor, friend, or relative; and violence) in the general adult population. Effects of psychiatric disorders were exerted mostly through a general psychopathology factor representing the shared effect across all disorders, independent of sociodemographic characteristics and the presence of the adverse outcomes at baseline. Violence and legal problems were further associated with the externalizing factor, but there were no independent associations of the internalizing factor or any individual psychiatric disorders with any of the adverse outcomes. Our findings reveal that associations between psychiatric disorders and adverse outcomes occur through broad psychological dimensions. Understanding the biological and psychological mechanisms underlying these dimensions should yield key intervention targets to decrease the individual suffering and societal burden associated with common psychiatric disorders.

Prevalence and correlates of anger in the community: results from a national survey.

INTRODUCTION: Little is known about the prevalence and correlates of anger in the community. METHODS: We used data derived from a large national sample of the U.S. population, which included more than 34,000 adults ages 18 years and older. We defined inappropriate, intense, or poorly controlled anger by means of self-report of the following: (1) anger that was triggered by small things or that was difficult to control, (2) frequent temper outbursts or anger that lead to loss of control, or (3) hitting people or throwing objects in anger. RESULTS: The overall prevalence of inappropriate, intense, or poorly controlled anger in the U.S. population was 7.8%. Anger was especially common among men and younger adults, and was associated with decreased psychosocial functioning. Significant and positive associations were evident between anger and parental factors, childhood, and adulthood adverse events. There were strong associations between anger and bipolar disorder, drug dependence, psychotic disorder, borderline, and schizotypal personality disorders. There was a dose-response relationship between anger and a broad range of psychopathology. CONCLUSIONS: A rationale exists for developing screening tools and early intervention strategies, especially for young adults, to identify and help reduce anger.

Obesity and the three-year longitudinal course of bipolar disorder.

OBJECTIVES: Despite substantial cross-sectional evidence that obesity is associated with an increased medical and psychiatric burden in bipolar disorder (BD), few longitudinal studies have examined this topic. METHODS: Subjects with BD (n = 1600) who completed both Wave 1 and Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were included. Analyses examined the association between obesity at Wave 1, and the subsequent course of BD, and of psychiatric and medical comorbidities, between Wave 1 and Wave 2. RESULTS: BD subjects with obesity (n = 506; 29.43%), compared to BD subjects without obesity (n = 1094; 70.57%) were significantly more likely to have a major depressive episode and to receive counseling for depression during follow-up, more likely to report a lifetime suicide attempt, and less likely to develop new-onset alcohol use disorders. These differences were no longer significant, however, after controlling for baseline demographic variables. No significant differences in new episodes or treatment of mania/hypomania were observed. After controlling for demographic variables, obese subjects remained significantly more likely to report any new-onset medical condition [odds ratio (OR) = 2.32, 95% confidence interval (CI): 1.63-3.30], new-onset hypertension (OR = 1.81, 95% CI: 1.16-2.82) and arthritis (OR = 1.64, 95% CI: 1.07-2.52). Obese subjects were significantly more likely to report physician-diagnosed diabetes (OR = 6.98, 95% CI: 4.27-11.40) and hyperlipidemia (OR = 2.32, 95% CI: 1.63-3.30) (assessed in Wave 2 only). The incidence of heart attacks was doubled among obese subjects, although this difference was not statistically significant. CONCLUSIONS: The association between obesity and increased prospective depressive burden appears to be explained by baseline demographic variables. By contrast, obesity independently predicts the accumulation of medical conditions among adults with BD. Treatment of obesity could potentially mitigate the psychiatric and medical burden of BD.

Prevalence and correlates of difficulty discarding: results from a national sample of the US population.

This study presents nationally representative data on the prevalence and the correlates of difficulty discarding, a behavior described in many psychiatric disorders, including a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, called hoarding disorder. Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions, a national sample of the US population (N=43,093). Difficulty discarding worn-out/worthless items (assessed by a single item) and diagnoses of psychiatric disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule. The prevalence of difficulty discarding worn-out/worthless items in the general population was 20.6%. Difficulty discarding strongly correlated with axis I and axis II disorders, level of impairment, and use of mental health services. Difficulty discarding worn-out/worthless items is a common behavior that can be associated with various forms of psychopathology. When reported in a clinical setting, it may signal that careful assessment is needed to clarify diagnosis and inform treatment strategies.

Approximating defense mechanisms in a national study of adults: prevalence and correlates with functioning.

Despite the clinical relevance of defense mechanisms, there are no published studies in nationally representative samples of their prevalence, correlates, and association with psychosocial functioning. We sought to estimate the prevalence and correlates of 12 defense mechanisms in the general adult population by approximating from items used to assess personality traits in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a representative sample of US adults (N = 36,653). We examined the associations between sociodemographic characteristics and prevalence of 3 types of defenses mechanisms (pathological, immature, and neurotic). For each defense mechanism, we used the Short-Form 12 to compare psychosocial functioning among 3 groups: those who (1) endorsed the mechanism with self-recognized impairment, (2) endorsed the mechanism without self-recognized impairment, and (3) did not endorse the defense mechanism. The prevalence of defense mechanisms ranged from 13.2% (splitting) to 44.5% (obsessive/controlling behavior). Pathological defenses were more strongly associated with immature defenses (OR = 5.4, 95% CI = 5.2-5.6) than with neurotic defenses (OR = 2.0, 95% CI = 1.9-2.0), whereas the association between immature and neurotic defenses had an intermediate value between the other two (OR = 2.2, 95% CI = 2.1-2.2). Pathological and immature defenses were associated with younger age, having been never married, lower educational attainment, and lower income. After adjusting the crude results for age and sex, individuals who did not endorse a given defense generally had higher scores on the mental health component of the SF-12 than those who endorsed the defense without self-recognized impairment who, in turn, had on average higher scores than those with self-recognized impairment. These results suggest that neurotic, immature, and pathological defense mechanisms are prevalent in the general population and associated with psychosocial impairment. Recognizing defense mechanisms may be important in clinical practice regardless of treatment modality.

Influence of comorbid mental disorders on time to seeking treatment for major depressive disorder.

BACKGROUND: Although treatment of depression has increased in recent years, long delays commonly separate disorder onset from first treatment contact. OBJECTIVES: This study evaluates the effects of psychiatric comorbidities and sociodemographic characteristics on lifetime treatment seeking and speed to first treatment contact for major depressive disorder (MDD). MEASURES: A cross-sectional epidemiological survey including retrospective structured assessments of DSM-IV MDD and other psychiatric disorders, respondent age at disorder onset, and age at first treatment contact. SUBJECTS: A nationally representative sample of 5958 adults aged at least 18 years residing in households and group quarters who met lifetime criteria for MDD. DATA ANALYSIS: The percentage of respondents with lifetime MDD who reported ever seeking treatment is reported overall and stratified by sociodemographic characteristics. Unadjusted and adjusted hazard ratios (AHRs) are presented on time to first depression treatment seeking by sociodemographic characteristics and comorbid psychiatric disorders. RESULTS: A majority (61.3%) of respondents with MDD reported having sought treatment for depression at some point in their lives. Time to first depression treatment contact was significantly related to the occurrence of comorbid panic disorder [AHR=2.01, 95% confidence interval (CI), 1.69-2.39], generalized anxiety disorder (AHR=1.55; 95% CI, 1.33-1.81), drug dependence (AHR=1.54; 95% CI, 1.06-2.26), dysthymic disorder (AHR=1.54; 95% CI, 1.35-1.76), and posttraumatic stress disorder (AHR=1.34; 95% CI, 1.13-1.59) and inversely related to male sex (AHR=0.74; 95% CI, 0.66-0.82) and black race/ethnicity (AHR=0.69, 95% CI, 0.59-0.81). CONCLUSIONS: Comorbid psychiatric disorders, especially panic, generalized anxiety, substance use, and dysthymic disorders, appear to play an important role in accelerating treatment seeking for MDD. Outreach efforts should include a focus on depressed individuals without complicating psychiatric comorbidities.

The burden of obesity among adults with bipolar disorder in the United States.

OBJECTIVES: Previous studies of clinical samples of adults with bipolar disorder (BD) suggest that there is increased prevalence of obesity and that obesity is associated with greater BD severity. We therefore examined this topic in a representative epidemiologic sample. METHODS: The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions was used to determine whether the prevalence of obesity is elevated among subjects with lifetime BD, and whether obesity is associated with greater severity of BD. RESULTS: The age-, race-, and sex-adjusted prevalence of obesity was significantly greater among subjects with BD versus controls [odds ratio (OR) = 1.65, 95% confidence interval (CI): 1.45-1.89, p < 0.001]. Obesity among subjects with BD was significantly positively associated with greater age, female sex, comorbid anxiety and medical conditions, and depression-related treatment utilization, and significantly negatively associated with past-year substance use disorder (SUD). In multivariable analyses, obesity among adults with BD was positively associated with age, comorbid anxiety disorders, duration of depressive episodes, and history of hospitalization for depression, and negatively associated with past-year SUD. CONCLUSIONS: The increased prevalence of obesity in BD and its association with illness severity, particularly in relation to depression, cannot be attributed to biases inherent in treatment-seeking samples. Future studies are needed to examine the direction of the observed associations and to develop preventive and treatment strategies seeking to mitigate the burden of obesity in BD.

Epidemiology of chronic and nonchronic major depressive disorder: results from the national epidemiologic survey on alcohol and related conditions.

BACKGROUND: Burden related to major depressive disorder (MDD) derives mostly from long-term occurrence of symptoms. This study aims to examine the prevalence, sociodemographic correlates, patterns of 12-month and lifetime psychiatric comorbidity, lifetime risk factors, psychosocial functioning, and mental health service utilization of chronic major depressive disorder (CMDD) compared to nonchronic major depressive disorder. METHODS: Face-to-face interviews were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093). RESULTS: The 12-month and lifetime prevalence of CMDD within the population meeting criteria for MDD was 26.5% and 24.0%, respectively. Individuals reporting a chronic course of MDD were socioeconomically and educationally disadvantaged, tended to be older, report loss of spouse or history of divorce, live in rural areas, have public assistance, low self-esteem, worse overall health and more likely to report comorbidities, most importantly dysthymia, generalized anxiety disorder, avoidant, and dependant personality disorder. Individuals with chronic MDD were more likely to report familial but not childhood onset risk factors for MDD. Those suffering CMDD were more likely to seek and receive mental health care than other forms of MDD, even though it took longer to start treatment. CONCLUSION: Chronic course of MDD is related to still worse socioeconomic conditions, educational achievement, more comorbidities, and family risk factors, although other courses of MDD carried greater risk of unmet treatment.

Adolescents With Attention-Deficit/Hyperactivity Disorder: Adverse Behaviors and Comorbidity.

PURPOSE AND OBJECTIVE: There is growing evidence that adolescents with ADHD develop long-term impairments and adverse outcomes, yet less is known about their adverse behaviors. To quantify rates of mental health comorbidities in adolescents with ADHD and compare the risks of adverse behaviors among adolescents with and without ADHD. METHODS: We performed a cohort analysis of 6,483 youth from the National Comorbidity Survey Adolescent Supplement (NCS-A), a nationally representative in-person structured diagnostic interview of adolescents aged 14-18 years focusing on mental, emotional, and behavioral disorders. MAIN OUTCOMES: (1) Percentages with comorbid anxiety, mood, disruptive behavior, and substance use disorders. (2) Strength of associations of ADHD with several adverse behaviors, including suicidal symptoms, aggression, behavior regulation, life events, education, and substance use. Odds ratios were adjusted for age, sex, and race. RESULTS: Among the sample of 6,483 adolescents, overall, 9.5% met the criteria for ADHD. Most (69.5%) of adolescents with ADHD had at least one comorbid mental health condition. As compared to adolescents without ADHD, those with ADHD were significantly more likely to have had a suicide attempt (aOR 2.9, 95% CI = 1.3-6.6) and to have had perpetrated physical aggression (aOR 2.3, 95% CI = 1.7-3.2). Adolescents with ADHD were also more likely to have been expelled from school or fired from a job (aOR 3.3, 95% CI = 1.7-6.5) and to have had problems related to drinking alcohol (95% CI = 1.2-2.9). CONCLUSIONS: ADHD in adolescents is a complicated disorder with elevated risks for a wide range of adverse behaviors.

Sex differences on the relation between major depressive disorder and labor market outcomes: A national prospective study.

To ascertain the direction of causality and differences by sex between major depressive disorder (MDD) and labor market outcomes in the US population, we used structural equation models separately for males and females to assess prospectively the interdependency of depression and labor market outcomes at Waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. Diagnosis of MDD used DSM-IV criteria. We found that MDD at Wave 1 predicted being out of the labor force for males at Wave 2 (p = 0.006) and being in the labor force at Wave 1 was associated with lower probability of MDD at Wave 2 (p = 0.049). Among males in the labor force, MDD at Wave 1 was negatively associated with employment at Wave 2 (p = 0.047), and employment at Wave 1 was negatively associated with MDD at Wave 2 (p < 0.001). For women, there was no association between MDD and labor force participation. However, among women in the labor force, MDD at Wave 1 was negatively associated with employment at Wave 2 (p = 0.013) and being employed at Wave 1 was negatively associated with MDD at Wave 2 (p < 0.0001). These results indicate that MDD and negative labor market outcomes are associated with one another at both time points, but the effects differ by sex. To reduce the economic and social burden of MDD, these differences should be considered in clinical practice, vocational rehabilitation, and in the design of social policies.

Disordered gambling among racial and ethnic groups in the US: results from the national epidemiologic survey on alcohol and related conditions.

INTRODUCTION: Prior research suggests that racial minority groups in the United States are more vulnerable to develop a gambling disorder than whites. However, no national survey on gambling disorders exists that has focused on ethnic differences. METHODS: Analyses of this study were based on the National Epidemiologic Survey on Alcohol and Related Conditions, a large (N=43,093) nationally representative survey of the adult (> or =18 years of age) population residing in households during 2001-2002 period. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision diagnoses of pathological gambling, mood, anxiety, drug use, and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. RESULTS: Prevalence rates of disordered gambling among blacks (2.2%) and Native/Asian Americans (2.3%) were higher than that of whites (1.2%). Demographic characteristics and psychiatric comorbidity differed among Hispanic, black, and white disordered gamblers. However, all racial and ethnic groups evidenced similarities with respect to symptom patterns, time course, and treatment seeking for pathological gambling. CONCLUSION: The prevalence of disordered gambling, but not its onset or course of symptoms, varies by racial and ethnic group. These varying prevalence rates may reflect, at least in part, cultural differences in gambling and its acceptability and accessibility. These data may inform the need for targeted prevention strategies for high-risk racial and ethnic groups.

Toward a Comprehensive Developmental Model of Prescription Opioid Use Disorder.

OBJECTIVE: To develop a comprehensive etiologic model of DSM-5 prescription opioid use disorder (POUD) based on Kendler and colleagues' development model for major depressive disorder. METHODS: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013). Risk factors were divided into 4 developmental tiers (childhood/early adolescence, late adolescence, adulthood, past year). Hierarchical logistic regression models were used to examine the independent contribution of each risk factor. Separate models were built to predict 12-month nonmedical use of prescription opioids and risk of POUD among those with 12-month nonmedical use. RESULTS: After adjustment for other risk factors, the odds of past 12-month nonmedical use of prescription opioids were increased by history of trauma, social deviance, and use of drugs other than opioids in adulthood and by past-year pain, alcohol use disorder (AUD), tobacco use disorder, any Axis I disorder other than SUD, and number of stressful events. History of POUD in adulthood and pain, AUD, tobacco use disorder, and any Axis I disorder other than substance use disorders (SUD) in the past year increased the odds of 12-month POUD. History of SUD other than POUD in adulthood was associated with lower odds of POUD. For both outcomes, the effect of earlier development tiers was mediated by more proximal ones. CONCLUSIONS: A modification of Kendler and colleagues' model for major depressive disorder provides a useful foundation for a comprehensive developmental model of nonmedical opioid use and opioid use disorder.

E-cigarette Use Among Young Adults in the U.S.

INTRODUCTION: Use of e-cigarettes is increasing among young adults in the U.S. Whether e-cigarette use serves as an aid to smoking reduction or cessation among young adults remains a matter of contention. This analysis examines patterns of e-cigarette use in relation to cigarette smoking in a nationally representative sample of U.S. young adults. METHODS: Data were analyzed from nationally representative U.S. adults, aged 18 to 35years (N=12,415), in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. Logistic regression assessed associations between e-cigarette use and smoking intensity, continuity, and reduction while controlling for several potential confounding factors. Data were analyzed in 2018. RESULTS: Among cigarette smokers, e-cigarette use was associated with higher odds of tobacco use disorder (AOR=2.58, 95% CI=1.73, 3.83) and daily cigarette smoking (AOR=1.67, 95% CI=1.73, 3.83). Among adults aged 26-35years, e-cigarette use was also associated with heavy cigarette smoking (AOR=2.01, 95% CI=1.09, 3.74). Among lifetime smokers, e-cigarette use was associated with lower odds of stopping smoking (AOR=0.14, 95% CI=0.08, 0.23) and lower odds of a 50% reduction in cigarettes smoked per day (AOR=0.63, 95% CI=0.43, 0.93). Only 13.1% of young adults who ever used e-cigarettes reported using them to help stop or quit smoking. CONCLUSIONS: Use of e-cigarettes by U.S. young adults, most of which is not intended to help reduce smoking, is related to more rather than less frequent and intensive cigarette smoking.

Treatment of Common Mental Disorders in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III.

OBJECTIVE: This study analyzed past 12-month disorder-specific mental health treatment patterns of common DSM-5 disorders in the United States. METHODS: Nationally representative face-to-face household survey data from structured diagnostic interviews of the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) (n = 36,309) were used to estimate percentages of respondents with 12-month DSM-5 mood, anxiety, and substance use disorders who received disorder-specific treatment during the 12 months before the interview. RESULTS: The percentage receiving treatment was highest for mood disorders (37.8%; 95% CI, 36.1%-39.6%), followed by anxiety disorders (24.1%; 95% CI, 22.6%-25.6%), and lowest for substance use disorders (18.8%; 95% CI, 17.8%-19.8%). Among anxiety disorders, panic disorder (47.9%; 95% CI, 43.9%-52.0%) had the highest treatment rate, and among substance use disorders, tobacco use disorder (20.3%; 95% CI, 19.0%-21.7%) had the highest treatment rate. Adults with mood and anxiety disorders (53.1%; 95% CI, 49.7%-56.4%) were more likely than those with only mood (32.0%; 95% CI, 29.5%-34.6%) or only anxiety (13.2%; 95% CI, 11.6%-15.0%) disorders to receive any mental health treatment. Lack of insurance coverage was associated with significantly lower odds of treatment for all disorders except specific phobia (0.55; 95% CI, 0.30-1.03), drug use disorders other than tobacco (0.80; 95% CI, 0.47-1.36), and alcohol use disorder (1.52; 95% CI, 1.12-2.07). CONCLUSIONS: Most adults with common mental disorders in the United States were not treated for their disorders, and treatment rates varied considerably across disorders and sociodemographic groups, with particularly low rates of treatment for substance use disorders. Policy and clinical interventions are needed to promote greater access to treatment of adults with common substance use, anxiety, and mood disorders.

Generalizability of clinical trials for alcohol dependence to community samples.

There is a growing concern that results of tightly controlled clinical trials of individuals with alcohol use disorders may not generalize to broader community samples. To assess the proportion of community-dwelling adults with alcohol dependence who would have been eligible for a typical alcohol dependence treatment study, we developed a new, simple method: we applied a standard set of eligibility criteria commonly used in alcohol outcome studies to a large (n=43,093) representative US adult sample interviewed face-to-face, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). We found that approximately one-half (50.5%) of all individuals with a DSM-IV diagnosis of alcohol dependence (n=1484) and 79.4% of those who sought treatment (n=185) were excluded by one or more study criteria. Individual study criteria excluded from 0.9% to 48.2% of the overall sample and 0.8% to 43.7% of the treatment-seeking sample. For the overall sample, the lack of motivation/compliance and financial situation criteria excluded the largest percentage of individuals. In the treatment-seeking subsample, comorbid medical conditions and legal problems excluded the largest proportions of individuals. Our study provides a new method to assess the generalizability of clinical trials, and gives further evidence that typical clinical trials for alcohol dependence likely exclude most adults with the disorder in the community and under care, and support the notion that clinical trials recruit "pure" rather than "typical" patients. Clinical trials should carefully evaluate the effects of the selected eligibility criteria on the generalizability of their results.

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.

Insomnia and Impaired Quality of Life in the United States.

OBJECTIVE: This analysis characterizes the individual-level and population-level burden of insomnia in relation to other medical conditions and describes the comorbidity of insomnia with other medical conditions, including the dependence of these comorbidities on pain, life events, and mental disorders. METHODS: Information from 34,712 adults in the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013) was analyzed. Quality-adjusted life-years (QALYs) were measured with the SF-6D, a 6-dimensional health state classification derived from the Short-Form-12, version 2. RESULTS: In the last 12 months, 27.3% of adults reported insomnia. The US annual loss of QALYs associated with insomnia (5.6 million; 95% CI, 5.33-5.86 million) was significantly larger than that associated with any of the other 18 medical conditions assessed, including arthritis (4.94 million; 95% CI, 4.62-5.26 million), depression (4.02 million; 95% CI, 3.87-4.17 million), and hypertension (3.63 million; 95% CI, 3.32-3.93 million). After control for demographic factors, all conditions examined from obesity (adjusted odds ratio [aOR] = 1.25) to mania (aOR = 5.04) were associated with an increased risk of insomnia. Further controlling for pain, stressful life events, and mental disorders decreased the odds of the co-occurrence of insomnia with these conditions. The decrease in insomnia comorbidity associated with pain was greatest for fibromyalgia (31.8%) and arthritis (20.1%); the decrease in insomnia comorbidity associated with life events was greatest for mania (13.4%) and drug use disorders (11.2%); and the decrease in insomnia comorbidity associated with mental disorders was greatest for peptic ulcer disease (11.2%) and liver diseases (11.1%). CONCLUSIONS: Insomnia is prevalent and associated with substantial population-level burden in self-assessed health. The co-occurrence of insomnia with common medical conditions is differentially related to pain and to a lesser extent to stressful life events and mental disorders.

Declining Health-Related Quality of Life in the U.S.

INTRODUCTION: Despite recent declining mortality of the U.S. population from most leading causes, uncertainty exists over trends in health-related quality of life. METHODS: The 2001-2002 and 2012-2013 National Epidemiologic Surveys on Alcohol and Related Conditions U.S. representative household surveys were analyzed for trends in health-related quality of life (n=79,402). Health-related quality of life was measured with the Short Form-6 Dimension scale derived from the Short Form-12. Changes in mean Short Form-6 Dimension ratings were attributed to changes in economic, social, substance abuse, mental, and medical risk factors. RESULTS: Mean Short Form-6 Dimension ratings decreased from 0.820 (2001-2002) to 0.790 (2012-2013; p<0.0001). In regressions adjusted for age, sex, race/ethnicity, and education, variable proportions of this decline were attributable to medical (21.9%; obesity, cardiac disease, hypertension, arthritis, medical injury), economic (15.6%; financial crisis, job loss), substance use (15.3%; substance use disorder or marijuana use), mental health (13.1%; depression and anxiety disorders), and social (11.2%; partner, neighbor, or coworker problems) risks. In corresponding adjusted models, a larger percentage of the decline in Short Form-6 Dimension ratings of older adults (aged ≥55 years) was attributable to medical (35.3%) than substance use (7.4%) risk factors, whereas the reverse occurred for younger adults (aged 18-24 years; 5.7% and 19.7%) and adults aged 25-44 years (12.7% and 16.3%). CONCLUSIONS: Between 2001-2002 and 2012-2013, there was a significant decline in average quality of life ratings of U.S. adults. The decline was partially attributed to increases in several modifiable risk factors, with medical disorders having a larger role than substance use disorders for older adults but the reverse for younger and middle-aged adults.

Cannabis Use and Risk of Prescription Opioid Use Disorder in the United States.

OBJECTIVE: The authors sought to determine whether cannabis use is associated with a change in the risk of incident nonmedical prescription opioid use and opioid use disorder at 3-year follow-up. METHOD: The authors used logistic regression models to assess prospective associations between cannabis use at wave 1 (2001-2002) and nonmedical prescription opioid use and prescription opioid use disorder at wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. Corresponding analyses were performed among adults with moderate or more severe pain and with nonmedical opioid use at wave 1. Cannabis and prescription opioid use were measured with a structured interview (the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV version). Other covariates included age, sex, race/ethnicity, anxiety or mood disorders, family history of drug, alcohol, and behavioral problems, and, in opioid use disorder analyses, nonmedical opioid use. RESULTS: In logistic regression models, cannabis use at wave 1 was associated with increased incident nonmedical prescription opioid use (odds ratio=5.78, 95% CI=4.23-7.90) and opioid use disorder (odds ratio=7.76, 95% CI=4.95-12.16) at wave 2. These associations remained significant after adjustment for background characteristics (nonmedical opioid use: adjusted odds ratio=2.62, 95% CI=1.86-3.69; opioid use disorder: adjusted odds ratio=2.18, 95% CI=1.14-4.14). Among adults with pain at wave 1, cannabis use was also associated with increased incident nonmedical opioid use (adjusted odds ratio=2.99, 95% CI=1.63-5.47) at wave 2; it was also associated with increased incident prescription opioid use disorder, although the association fell short of significance (adjusted odds ratio=2.14, 95% CI=0.95-4.83). Among adults with nonmedical opioid use at wave 1, cannabis use was also associated with an increase in nonmedical opioid use (adjusted odds ratio=3.13, 95% CI=1.19-8.23). CONCLUSIONS: Cannabis use appears to increase rather than decrease the risk of developing nonmedical prescription opioid use and opioid use disorder.

Causes of Death After Nonfatal Opioid Overdose.

Importance: A recent increase in patients presenting with nonfatal opioid overdoses has focused clinical attention on characterizing their risks of premature mortality. Objective: To describe all-cause mortality rates, selected cause-specific mortality rates, and standardized mortality rate ratios (SMRs) of adults during their first year after nonfatal opioid overdose. Design, Setting, and Participants: This US national longitudinal study assesses a cohort of patients aged 18 to 64 years who were Medicaid beneficiaries and experienced nonfatal opioid overdoses. The Medicaid data set included the years 2001 through 2007. Death record information was obtained from the National Death Index. Data analysis occurred from October 2017 to January 2018. Main Outcomes and Measures: Crude mortality rates per 100 000 person-years were determined in the first year after nonfatal opioid overdose. Standardized mortality rate ratios (SMR) were estimated for all-cause and selected cause-specific mortality standardized to the general population with respect to age, sex, and race/ethnicity. Results: The primary cohort included 76 325 adults and 66 736 person-years of follow-up. During the first year after nonfatal opioid overdose, there were 5194 deaths, the crude death rate was 778.3 per 10 000 person-years, and the all-cause SMR was 24.2 (95% CI, 23.6-24.9). The most common immediate causes of death were substance use-associated diseases (26.2%), diseases of the circulatory system (13.2%), and cancer (10.3%). For every cause examined, SMRs were significantly elevated, especially with respect to drug use-associated diseases (SMR, 132.1; 95% CI, 125.6-140.0), HIV (SMR, 45.9; 95% CI, 39.5-53.0), chronic respiratory diseases (SMR, 41.1; 95% CI, 36.0-46.8), viral hepatitis (SMR, 30.6; 95% CI, 22.9-40.2), and suicide (SMR, 25.9; 95% CI, 22.6-29.6), particularly including suicide among females (SMR, 47.9; 95% CI, 39.8-52.3). Conclusions and Relevance: In a US national cohort of adults who had experienced a nonfatal opioid overdose, a marked excess of deaths was attributable to a wide range of substance use-associated, mental health, and medical conditions, underscoring the importance of closely coordinating the substance use, mental health, and medical care of this patient population.