Contributions of the social environment to first-onset and recurrent mania.

In treated cohorts, individuals with bipolar disorder are more likely to report childhood adversities and recent stressors than individuals without bipolar disorder; similarly, in registry-based studies, childhood adversities are more common among individuals who later become hospitalized for bipolar disorder. Because these types of studies rely on treatment-seeking samples or hospital diagnoses, they leave unresolved the question of whether or not social experiences are involved in the etiology of bipolar disorder. We investigated the role of childhood adversities and adulthood stressors in liability for bipolar disorder using data from the National Epidemiologic Survey on Alcohol and Related Conditions (n=33 375). We analyzed risk for initial-onset and recurrent DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) manic episodes during the study's 3-year follow-up period. Childhood physical abuse and sexual maltreatment were associated with significantly higher risks of both first-onset mania (odds ratio (OR) for abuse: 2.23; 95% confidence interval (CI)=1.71, 2.91; OR for maltreatment: 2.10; CI=1.55, 2.83) and recurrent mania (OR for abuse: 1.55; CI=1.00, 2.40; OR for maltreatment: 1.60; CI=1.00, 2.55). In addition, past-year stressors in the domains of interpersonal instability and financial hardship were associated with a significantly higher risk of incident and recurrent mania. Exposure to childhood adversity potentiated the effects of recent stressors on adult mania. Our findings demonstrate a role of social experiences in the initial onset of bipolar disorder, as well as in its prospective course, and are consistent with etiologic models of bipolar disorder that implicate deficits in developmentally established stress-response pathways.

Psychosocial stressors and the prognosis of major depression: a test of Axis IV.

BACKGROUND: Axis IV is for reporting 'psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental disorders'. No studies have examined the prognostic value of Axis IV in DSM-IV. METHOD: We analyzed data from 2497 participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) with major depressive episode (MDE). We hypothesized that psychosocial stressors predict a poor prognosis of MDE. Secondarily, we hypothesized that psychosocial stressors predict a poor prognosis of anxiety and substance use disorders. Stressors were defined according to DSM-IV's taxonomy, and empirically using latent class analysis (LCA). RESULTS: Primary support group problems, occupational problems and childhood adversity increased the risks of depressive episodes and suicidal ideation by 20-30%. Associations of the empirically derived classes of stressors with depression were larger in magnitude. Economic stressors conferred a 1.5-fold increase in risk for a depressive episode [95% confidence interval (CI) 1.2-1.9]; financial and interpersonal instability conferred a 1.3-fold increased risk of recurrent depression (95% CI 1.1-1.6). These two classes of stressors also predicted the recurrence of anxiety and substance use disorders. Stressors were not related to suicidal ideation independent from depression severity. CONCLUSIONS: Psychosocial and environmental problems are associated with the prognosis of MDE and other Axis I disorders. Although DSM-IV's taxonomy of stressors stands to be improved, these results provide empirical support for the prognostic value of Axis IV. Future work is needed to determine the reliability of Axis IV assessments in clinical practice, and the usefulness of this information to improving the clinical course of mental disorders.

Changing Parental Knowledge and Treatment Acceptance for ADHD: A Pilot Study.

This pilot study assessed the feasibility and potential effectiveness of a single-session workshop in modifying parental beliefs/knowledge about attention-deficit/hyperactivity disorder (ADHD) in children and impact on treatment acceptance/utilization. Concerns raised by school professionals about lack of treatment follow-through after ADHD diagnosis and parental misinformation about medication usage catalyzed this project. A single-group pre-post quasi-experimental design was used. Sixty-eight parents completed ADHD knowledge/belief scales and stress inventories, and pre-ADHD and post-ADHD information workshop. Follow-up calls were made after the workshop to assess treatment utilization. Parents/caregivers experienced significant knowledge and belief changes regarding medication efficacy, willingness to accept physician treatment recommendations, and rejection of non-empirically based treatments. Follow-up data showed that 41% of contacted participants met with physicians to discuss medication utilization and behavioral treatments. Brief, one-session psycho-educational workshops were feasible and impacted parental beliefs and behaviors regarding scientifically supported interventions for ADHD.

Suicidality, ethnicity and immigration in the USA.

BACKGROUND: Suicide is the 11th leading cause of death in the USA. Suicide rates vary across ethnic groups. Whether suicide behavior differs by ethnic groups in the USA in the same way as observed for suicide death is a matter of current discussion. The aim of this report was to compare the lifetime prevalence of suicide ideation and attempt among four main ethnic groups (Asians, Blacks, Hispanics, and Whites) in the USA. METHOD: Suicide ideation and attempts were assessed using the World Mental Health version of the Composite International Diagnostic Interview (WMH-CIDI). Discrete time survival analysis was used to examine risk for lifetime suicidality by ethnicity and immigration among 15 180 participants in the Collaborative Psychiatric Epidemiological Surveys (CPES), a group of cross-sectional surveys. RESULTS: Suicide ideation was most common among Non-Hispanic Whites (16.10%), least common among Asians (9.02%) and intermediate among Hispanics (11.35%) and Non-Hispanic Blacks (11.82%). Suicide attempts were equally common among Non-Hispanic Whites (4.69%), Hispanics (5.11%) and Non-Hispanic Blacks (4.15%) and less common among Asians (2.55%). These differences in the crude prevalence rates of suicide ideation decreased but persisted after control for psychiatric disorders, but disappeared for suicide attempt. Within ethnic groups, risk for suicidality was low among immigrants prior to migration compared to the US born, but equalized over time after migration. CONCLUSIONS: Ethnic differences in suicidal behaviors are explained partly by differences in psychiatric disorders and low risk prior to arrival in the USA. These differences are likely to decrease as the US-born proportion of Hispanics and Asians increases.

Classes of conduct disorder symptoms and their life course correlates in a US national sample.

BACKGROUND: Population data on conduct disorder (CD) symptoms can help determine whether hypothesized subtypes of CD are sufficiently disparate in their familial, psychiatric and life course correlates to distinguish separate diagnostic entities. METHOD: Latent class analysis (LCA) of CD symptoms occurring before age 15 was conducted in a national sample of adults aged 18-44 years from the National Epidemiological Study of Alcohol and Related Conditions. Associations of latent class membership with parental behavior problems, onset of psychiatric disorders and anti-social behaviors after age 15, adolescent life events (e.g. high school drop-out), and past-year life events (e.g. divorce/separation, bankruptcy) were estimated. RESULTS: LCA identified a no-CD class with low prevalence of all symptoms, three intermediate classes - deceit/theft, rule violations, aggression - and a severe class. The prevalence of CD, according to DSM-IV criteria, was 0% in the no-CD class, between 13.33% and 33.69% in the intermediate classes and 62.20% in the severe class. Latent class membership is associated with all the familial, psychiatric and life course outcomes examined. Among the intermediate classes, risk for subsequent mood/anxiety disorders and anti-social behavior was higher in the deceit/theft and aggressive classes than in the rule violations class. However, risk for adolescent life events is highest in the rule violations class. CONCLUSIONS: CD symptoms tend to occur in a partially ordered set of classes in the general population. Prognostically meaningful distinctions can be drawn between classes, but only at low levels of symptoms.

Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States.

BACKGROUND: To identify sources of race/ethnic differences related to post-traumatic stress disorder (PTSD), we compared trauma exposure, risk for PTSD among those exposed to trauma, and treatment-seeking among Whites, Blacks, Hispanics and Asians in the US general population. METHOD: Data from structured diagnostic interviews with 34 653 adult respondents to the 2004-2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analysed. RESULTS: The lifetime prevalence of PTSD was highest among Blacks (8.7%), intermediate among Hispanics and Whites (7.0% and 7.4%) and lowest among Asians (4.0%). Differences in risk for trauma varied by type of event. Whites were more likely than the other groups to have any trauma, to learn of a trauma to someone close, and to learn of an unexpected death, but Blacks and Hispanics had higher risk of child maltreatment, chiefly witnessing domestic violence, and Asians, Black men, and Hispanic women had higher risk of war-related events than Whites. Among those exposed to trauma, PTSD risk was slightly higher among Blacks [adjusted odds ratio (aOR) 1.22] and lower among Asians (aOR 0.67) compared with Whites, after adjustment for characteristics of trauma exposure. All minority groups were less likely to seek treatment for PTSD than Whites (aOR range: 0.39-0.61), and fewer than half of minorities with PTSD sought treatment (range: 32.7-42.0%). CONCLUSIONS: When PTSD affects US race/ethnic minorities, it is usually untreated. Large disparities in treatment indicate a need for investment in accessible and culturally sensitive treatment options.

A multinational study of mental disorders, marriage, and divorce.

OBJECTIVE: Estimate predictive associations of mental disorders with marriage and divorce in a cross-national sample. METHOD: Population surveys of mental disorders included assessment of age at first marriage in 19 countries (n = 46,128) and age at first divorce in a subset of 12 countries (n = 30,729). Associations between mental disorders and subsequent marriage and divorce were estimated in discrete time survival models. RESULTS: Fourteen of 18 premarital mental disorders are associated with lower likelihood of ever marrying (odds ratios ranging from 0.6 to 0.9), but these associations vary across ages of marriage. Associations between premarital mental disorders and marriage are generally null for early marriage (age 17 or younger), but negative associations come to predominate at later ages. All 18 mental disorders are positively associated with divorce (odds ratios ranging from 1.2 to 1.8). Three disorders, specific phobia, major depression, and alcohol abuse, are associated with the largest population attributable risk proportions for both marriage and divorce. CONCLUSION: This evidence adds to research demonstrating adverse effects of mental disorders on life course altering events across a diverse range of socioeconomic and cultural settings. These effects should be included in considerations of public health investments in preventing and treating mental disorders.

Change in teachers' ratings of attention problems and subsequent change in academic achievement: a prospective analysis.

BACKGROUND: Recent research has documented a link between attention problems at school entry and later academic achievement. Little is known about the association of change in attention problems during the early school years with subsequent change in academic achievement. METHOD: A community-based cohort was followed up and assessed for attention problems at ages 6 and 11 (Teacher Report Form; TRF) and for academic achievement in math and reading at ages 11 and 17 (Woodcock-Johnson Psycho-Educational Battery). Complete data were available on 590 children (72% of the initial sample). Ordinary least squares regressions were used to estimate change in academic achievement from age 11 to age 17 in relation to change in TRF-attention problems from age 6 to age 11. Children's IQ and family factors were statistically controlled. RESULTS: Change in teachers' ratings of attention problems from age 6 to age 11 was negatively associated with change in math and reading from age 11 to age 17, controlling for children's IQ and family factors. Externalizing problems had no significant association with change in math or reading, when added to the multivariable model. CONCLUSIONS: Increases in teacher-rated attention problems from age 6 to age 11 were followed by declines in academic achievement from age 11 to age 17; decreases were followed by gains. The results underscore the need for research on the course of attention problems, the testing of interventions to address children's early attention problems and the evaluation of their effects on subsequent academic achievement.

A randomised test of the effect of medical v. lay idiom on assessment of perceived mental health condition in the USA.

AIMS: To test the impact of using different idioms in epidemiological interviews on the prevalence and correlates of poor mental health and mental health service use. METHODS: We conducted a randomised methodological experiment in a nationally representative sample of the US adult population, comparing a lay idiom, which asked about 'problems with your emotions or nerves' with a more medical idiom, which asked about 'problems with your mental health'. Differences across study arms in the associations of endorsement of problems with the Kessler-6 (a validated assessment of psychological distress), demographic characteristics, self-rated health and mental health service use were examined. RESULTS: Respondents were about half as likely to endorse a problem when asked with the more medical idiom (18.1%) than when asked with the lay idiom (35.1%). The medical idiom had a significantly larger area under the ROC curve when compared against a validated measure of psychological distress than the lay idiom (0.91 v. 0.87, p = 0.012). The proportion of the population who endorsed a problem but did not receive treatment in the past year was less than half as large for the medical idiom (7.90%) than for the lay idiom (20.94%). Endorsement of problems differed in its associations with age, sex, race/ethnicity and self-rated health depending on the question idiom. For instance, the odds of endorsing problems were threefold higher in the youngest than the oldest age group when the medical idiom was used (OR = 3.07; 95% CI 1.47-6.41) but did not differ across age groups when the lay idiom was used (OR = 0.76; 95% CI 0.43-1.36). CONCLUSION: Choice of idiom in epidemiological questionnaires can affect the apparent correlates of poor mental health and service use. Cultural change within populations over time may require changes in instrument wording to maintain consistency in epidemiological measurement of psychiatric conditions.

Mental disorders and termination of education in high-income and low- and middle-income countries: epidemiological study.

BACKGROUND: Studies of the impact of mental disorders on educational attainment are rare in both high-income and low- and middle-income (LAMI) countries. AIMS: To examine the association between early-onset mental disorder and subsequent termination of education. METHOD: Sixteen countries taking part in the World Health Organization World Mental Health Survey Initiative were surveyed with the Composite International Diagnostic Interview (n=41 688). Survival models were used to estimate associations between DSM-IV mental disorders and subsequent non-attainment of educational milestones. RESULTS: In high-income countries, prior substance use disorders were associated with non-completion at all stages of education (OR 1.4-15.2). Anxiety disorders (OR=1.3), mood disorders (OR=1.4) and impulse control disorders (OR=2.2) were associated with early termination of secondary education. In LAMI countries, impulse control disorders (OR=1.3) and substance use disorders (OR=1.5) were associated with early termination of secondary education. CONCLUSIONS: Onset of mental disorder and subsequent non-completion of education are consistently associated in both high-income and LAMI countries.

Immigration to the USA and risk for mood and anxiety disorders: variation by origin and age at immigration.

BACKGROUND: Risk for mood and anxiety disorders associated with US-nativity may vary across immigrant groups. METHOD: Using data from the National Epidemiological Study of Alcohol and Related Conditions (NESARC), we examined the association of lifetime risk for mood and anxiety disorders with US-nativity and age at immigration across seven subgroups of the US population defined by country or region of ancestral origin: Mexico, Puerto-Rico, Cuba, Central and South America, Western Europe, Eastern Europe, and Africa and the Caribbean. Discrete time survival models were used to compare lifetime risk between the US-born, immigrants who arrived in the USA prior to the age of 13 years and immigrants who arrived in the USA at the age of 13 years or older. RESULTS: The association of risk for mood and anxiety disorders with US-nativity varies significantly across ancestral origin groups (p<0.001). Among people from Mexico, Eastern Europe, and Africa or the Caribbean, risk for disorders is lower relative to the US-born among immigrants who arrived at the age of 13 years or higher (odds ratios in the range 0.34-0.49) but not among immigrants who arrived prior to the age of 13 years. There is no association between US-nativity and risk for disorder among people from Western Europe and Puerto Rico. CONCLUSIONS: Low risk among immigrants relative to the US-born is limited to groups among whom risk for mood and anxiety disorder is low in immigrants who spent their pre-adolescent years outside of the USA.

Associations of Perceived Discrimination With Impaired Functioning in a Population Sample With Psychological Distress.

OBJECTIVE: To test associations between perceived discrimination based on mental health status and impaired functioning in a population sample with psychological distress. METHODS: Interviews were conducted with a sample of respondents to the California Health Interview Survey with mild, moderate, or severe psychological distress. Perceived discrimination was assessed using 14 items covering four domains in which discrimination is reported: social, partner, institutional, and work. Associations of perceived discrimination scores (total score and domain scores) with impaired functioning, measured by the likelihood and number of days out of role, were estimated with statistical adjustment for demographic characteristics and serious psychological distress. RESULTS: Discrimination domain scores are significantly correlated (r ranging from .34 to .65).Total discrimination score is associated with having days out of role (OR = 1.20, 95% CI = 1.10-1.30) and with number of days out of role (5.5 days) after adjustment for demographics and psychological distress. The high correlation among the domain scores makes the attribution of association to particular domains uncertain. Removal of the effect of discrimination using model-based simulation reduces past-year days out of role by 39.4 (SE 11.3) days. CONCLUSIONS: This observational study supports the suggestion that discrimination against people with mental illness contributes to their impaired functioning in a diverse range of social roles. The results provide preliminary evidence that reduction in discrimination against people with mental illness could improve social functioning and work productivity. Correlations among domain scores make it difficult to draw conclusions about domain-specific associations.

Sex differences in recent first-onset depression in an epidemiological sample of adolescents.

Prior studies provide limited and contradictory evidence regarding sex differences in the incidence of depression during adolescence, a critical period for development of the disorder. Data from six consecutive years (2009-2014) of a national survey of US adolescents aged 12-17 (N=101 685) are used to characterize sex differences in the incidence of depression by age and to compare recent first-onset and persistent depression with respect to impairment, suicide attempts, conduct problems and academic functioning. Projecting from age-specific incidence proportions, the cumulative incidence of depression between the ages of 12 and 17 is 13.6% among male and 36.1% among female subjects. The sex difference in incidence is significant at the age of 12 years (5.2% in female versus 2.0% in male subjects, P<0.0001), and it is significantly larger at ages of 13 through 17 years than at the age of 12 years (P-values<0.05). Depression-related impairment is lower in recent first-onset than in persistent depression among female but not among male subjects. The prevalence of conduct problems and poor academic functioning is higher in both recent first-onset and persistent depression relative to those with no depression for both male and female subjects. The incidence of depression during adolescence is higher than that suggested by prior studies based on retrospective recall. Contrary to prior studies, evidence suggests that the sex difference in depression originates during childhood and grows in magnitude during adolescence. High levels of impairment, suicide attempts, conduct problems and poor academic functioning argue against a 'wait and see' approach to clinical treatment of recent first-onset depression.

Cost utility analysis of radiographic screening for an orbital foreign body before MR imaging.

BACKGROUND AND PURPOSE: Our purpose was to evaluate the cost-effectiveness of clinical versus radiographic screening for an orbital foreign body before MR imaging. METHODS: Costs of screening were determined on the basis of published reports, disability rating guides, and a practice survey. Base case estimates were derived from published guidelines. A single-state change model was constructed using social cost as the unit of analysis. Sensitivity analysis was performed for each variable. The benefit of screening was avoidance of immediate, permanent, nonameliorable, unilateral blindness. RESULTS: Using base case estimates and a discount rate of zero, we calculated the cost of the current guideline as $328,580 per quality-adjusted life-year saved. Sensitivity analysis identified screening cost as a critical variable. Discount rates and effectiveness of foreign body removal also were found to be important factors. Probability of injury and prevalence of foreign body may impact the analysis. CONCLUSION: Clinical screening before radiography increases the cost-effectiveness of foreign body screening by an order of magnitude, assuming base case ocular foreign body removal rates. Asking the patient "Did a doctor get it all out?" serves this purpose. Occupational history by itself is not sufficient to mandate radiographic orbital screening. Current practice guidelines for foreign body screening should be altered.

Phased-array surface coil MR of the orbits and optic nerves.

PURPOSE: To devise a practical technique for high-resolution evaluation of the anterior optic apparatus using a phased-array surface coil system, and to evaluate this system in patients with suspected optic pathway abnormalities. METHODS: A four-element phased-array coil pair was placed on each side of the head, and signal-to-noise measurements were obtained using a head phantom. Comparison between the phased-array coil, the quadrature coil, and a single-turn 12.7-cm (5-in) surface coil was done. T1 spin-echo and T2 fast spin-echo sequences were obtained in the oblique axial and oblique sagittal planes, to approximate the long axis of the optic nerves and the nonoblique coronal plane. RESULTS: The phantom signal-to-noise measurements at simulated locations of the optic nerve head, optic canal, and optic chiasm revealed an improvement of at least 30% using the phased-array system. Of 24 imaged cases, 9 had trauma, 5 had suspected neoplasms, and 2 had optic neuritis. In 3 patients, an unexpected diagnosis of optic pathway contusion or infarction was made. The remaining 8 patients had various suspected visual pathway lesions. CONCLUSION: Phased-array surface coils allow rapid, thin-section imaging of the entire anterior optic pathway, with improved signal-to-noise ratio. This may improve evaluation of optic pathway lesions over conventional techniques.

MR contrast media in neuroimaging: a critical review of the literature.

BACKGROUND AND PURPOSE: MR contrast media are commonly used but do not have evidence-based guidelines for their application. This investigation seeks to define specific methodological problems in the MR contrast media literature and to suggest guidelines for an improved study design. METHODS: To evaluate the reported clinical efficacy of MR contrast media in neuroimaging, we performed a critical review of the literature. From 728 clinical studies retrieved via MEDLINE, we identified 108 articles that evaluated contrast media efficacy for a minimum of 20 patients per study. The articles were randomly assigned to four readers (a fifth reader reviewed all of the articles) who were blinded to article titles, authors, institutions, and journals of publication. The readers applied objective, well-established methodological criteria to assign each article a rating of A, B, C, or D. RESULTS: One hundred one of 108 articles received a D rating, six received a C rating, and one received a B rating. In general, the Methods sections of the evaluated articles did not contain details that would allow the reader to calculate reliable measures of diagnostic accuracy, such as sensitivity and specificity. Specifically, a common problem was failure to establish and uniformly apply an acceptable standard of reference. In addition, images were not always interpreted independently from the reference standard. Radiologists and clinicians need to determine the applicability of any published study to their own practices. Unfortunately, the studies we reviewed commonly lacked clear descriptions of patient demographics, the spectrum of symptomatology, and the procedure for assembling the study cohort. Finally, small sample sizes with inadequate controls were presented in almost all of the articles. CONCLUSION: Although MR contrast media are widely used and play an essential role in lesion detection and confidence of interpretation, no rigorous studies exist to establish valid sensitivity and specificity estimates for their application. On the basis of this review, we herein describe basic methods to document improvements in technology. Such studies are essential to devise measures of diagnostic accuracy, which can form the basis for further studies that will assess diagnostic and therapeutic impact and, ultimately, patient outcomes.

Computer simulation of low-density lipoprotein removal in the presence of a bioreactor containing phospholipase A2.

High concentrations of low-density lipoproteins (LDL) in the blood can lead to coronary heart disease, the primary cause of death in the Western hemisphere. A new treatment to reduce LDL levels is now being tested on rabbits, which are model animals for hypercholesteremia. The treatment involves using an immobilized enzyme within a bioreactor that is incorporated in an extracorporeal circuit. The enzyme modifies LDL to a form that is much more rapidly removed from the circulation. A mathematical model to describe LDL metabolism in the presence of the bioreactor was developed to give a better understanding of the biodistribution of modified LDL during and following treatment. A four-compartment model was developed on the basis of previous studies on human lipid metabolism, with the specific values of the constants taken from the experimental data on rabbits. A Macintosh II computer with a Stella II modeling program was used to simulate the treatment and to predict LDL levels over time given different values for initial enzyme activity, length of treatment, rate of enzyme denaturation, and other relevant parameters. The model provided a close fit with the experimental results for the change in total cholesterol. It confirmed the observed delay in the plasma cholesterol rebound level after the end of the extracorporeal treatment. One conclusion derived from both the experimental data and the model is that during the first 1.5 h, the limiting step for LDL removal is the rate at which modified LDL is taken up by the liver.(ABSTRACT TRUNCATED AT 250 WORDS)

Socioeconomic aspects of spinal imaging: impact of radiological diagnosis on lumbar spine-related disability.

Low back pain presents a difficult problem for patients and their doctors. The symptom affects the majority of people at some point in their lives and usually has a benign natural history. However, as a society, we consume tremendous resources to diagnose and treat painful spinal disorders. Magnetic resonance imaging (MRI) facilitates the "medicalization" of low back pain due to its exquisitely sensitive depiction of pathoanatomy. Unfortunately, many of these findings are present in normal subjects. Radiologists should recognize the poor correlation between MRI findings and significant, treatable disease and support the use of evidence-based guidelines for patient referral. MRI studies should be interpreted stringently, to avoid unnecessary patient labeling and potentially inappropriate treatment.

Temperature contours and ghost surfaces for chaotic magnetic fields.

Steady state solutions for anisotropic heat transport in a chaotic magnetic field are determined numerically and compared to a set of "ghost surfaces"-surfaces constructed via an action-gradient flow between the minimax and minimizing periodic orbits. The ghost surfaces are in remarkable agreement with the temperature contours.

Education and race-ethnicity differences in the lifetime risk of alcohol dependence.

OBJECTIVES: While lower socioeconomic status (SES) is related to higher risk for alcohol dependence, minority race-ethnicity is often associated with lower risk. This study attempts to clarify the nature and extent of social inequalities in alcohol dependence by investigating the effects of SES and race-ethnicity on the development of alcohol dependence following first alcohol use. DESIGN: Cross-sectional analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093). Survival analysis was used to model alcohol dependence onset according to education, race-ethnicity and their interaction. SETTING: United States, 2001-2. RESULTS: Compared with non-Hispanic white people, age-adjusted and sex-adjusted risks of alcohol dependence were lower among black people (odds ratio (OR) = 0.70, 95% confidence interval (CI) = 0.63 to 0.78), Asians (OR = 0.65, CI = 0.49 to 0.86) and Hispanics (OR = 0.68, CI = 0.58 to 0.79) and higher among American Indians (OR = 1.37, CI = 1.09 to 1.73). Individuals without a college degree had higher risks of alcohol dependence than individuals with a college degree or more; however, the magnitude of risk varied significantly by race-ethnicity (chi(2) for the interaction between education and race-ethnicity = 19.7, df = 10, p = 0.03); odds ratios for less than a college degree were 1.12, 1.46, 2.24, 2.35 and 10.99 among Hispanics, white people, black people, Asians, and American Indians, respectively. There was no association between education and alcohol dependence among Hispanics. CONCLUSIONS: Race-ethnicity differences in the magnitude of the association between education and alcohol dependence suggest that aspects of racial-ethnic group membership mitigate or exacerbate the effects of social adversity.