Strong and weak cross-inheritance of substance use disorders in a nationally representative sample.

Substance use disorders (SUDs) are moderately to highly heritable and are in part cross-transmitted genetically, as observed in twin and family studies. We performed exome-focused genotyping to examine the cross-transmission of four SUDs: alcohol use disorder (AUD, n = 4487); nicotine use disorder (NUD, n = 4394); cannabis use disorder (CUD, n = 954); and nonmedical prescription opioid use disorder (NMPOUD, n = 346) within a large nationally representative sample (n = 36,309), the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). All diagnoses were based on in-person structured psychiatric interview (AUDADIS-5). SUD cases were compared alone and together to 3959 "super controls" who had neither a SUD nor a psychiatric disorder using an exome-focused array assaying 363,496 SNPs, yielding a representative view of within-disorder and cross-disorder genetic influences on SUDs. The 29 top susceptibility genes for one or more SUDs overlapped highly with genes previously implicated by GWAS of SUD. Polygenic scores (PGS) were computed within the European ancestry (EA) component of the sample (n = 12,505) using summary statistics from each of four clinically distinct SUDs compared to the 3959 "super controls" but then used for two distinctly different purposes: to predict SUD severity (mild, moderate, or severe) and to predict each of the other 3 SUDs. Our findings based on PGS highlight shared and unshared genetic contributions to the pathogenesis of SUDs, confirming the strong cross-inheritance of AUD and NUD as well as the distinctiveness of inheritance of opioid use disorder.

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 Past-Year Recovery From DSM-5 Alcohol Use Disorder: Results From National Epidemiologic Survey on Alcohol and Related Conditions-III.

BACKGROUND: Little is known about remission, recovery, and other outcomes of alcohol use disorder (AUD) as defined by the DSM-5. METHODS: Data from a large representative sample of the United States was used to examine correlates of past-year AUD status among individuals with prior-to-past-year AUD: persistent AUD, symptomatic high-risk drinking, asymptomatic high-risk drinking, symptomatic low-risk drinking, asymptomatic low-risk drinking (nonabstinent recovery, NAR), and abstainer (abstinent recovery, AR). Multiple logistic regression analyses were conducted to compare: (i) AR and NAR with persistent AUD, (ii) AR with NAR, and (iii) asymptomatic and symptomatic high-risk drinking with AR and NAR. RESULTS: Among individuals with AUD prior to past year (n = 7,785), 34.2% were classified with persistent AUD, 8.8 and 1.6% were symptomatic high-risk and symptomatic low-risk drinkers, respectively, 21.5% were asymptomatic high-risk drinkers, 17.9% were asymptomatic low-risk drinkers, and 16.0% were abstainers. One-quarter of individuals with AUD prior to past year achieved AR or NAR without the benefit of treatment, while a much greater percentage of individuals achieving AR (43.2%) reported receiving treatment relative to those with NAR (12.3%). The number of lifetime AUD symptoms was greater among those achieving AR (among the treated) and lower among those achieving NAR relative to persistent AUD. The number of AUD symptoms was also greater among those achieving AR than NAR and lower among asymptomatic and symptomatic risk drinkers relative to those achieving AR and NAR. Consumption was greater among those achieving AR relative to those achieving NAR and greater among asymptomatic and symptomatic risk drinkers relative to AR and NAR. Odds of achieving AR or NAR relative to persistent AUD were generally lower among non-Hispanic Blacks and those with higher education, greater among women and married individuals, and lower among illicit drug users and individuals with histories of a personality disorder or mood/anxiety disorder. CONCLUSIONS: There appears to be a substantial level of recovery from AUD. Information on specific factors associated with AUD outcomes can be useful in targeting appropriate treatment efforts.

Childhood interpersonal violence and adult alcohol, cannabis, and tobacco use disorders: variation by race/ethnicity?

BACKGROUND: Exposure to child maltreatment has been shown to increase lifetime risk for substance use disorders (SUD). However, this has not been systematically examined among race/ethnic groups, for whom rates of exposure to assaultive violence and SUD differ. This study examined variation by race/ethnicity and gender in associations of alcohol (AUD), cannabis (CUD), and tobacco (TUD) use disorders with three types of childhood interpersonal violence (cIPV): physical abuse, sexual abuse, and witnessing parental violence. METHOD: Data from the National Epidemiologic Survey of Alcohol-Related Conditions-III (N: 36 309), a US nationally representative sample, was utilized to examine associations of DSM-5 AUD, CUD and TUD with cIPV among men and women of five racial/ethnic groups. Models were adjusted for additional risk factors (e.g. parental substance use problems, participant's co-occurring SUD). RESULTS: Independent contributions of childhood physical and sexual abuse to AUD, CUD, and TUD, and of witnessing parental violence to AUD and TUD were observed. Associations of cIPV and SUD were relatively similar across race/ethnicity and gender [Odds Ratios (ORs) ranged from 1.1 to 1.9], although associations of physical abuse with AUD and TUD were greater among males, associations of parental violence and AUD were greater among females, and associations of parental violence with AUD were greater among Hispanic women and American Indian men. CONCLUSIONS: Given the paucity of research in this area, and the potential identification of modifiable risk factors to reduce the impact of childhood interpersonal violence on SUDs, further research and consideration of tailoring prevention and intervention efforts to different populations are warranted.

Dimensionality of DSM-5 posttraumatic stress disorder and its association with suicide attempts: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III.

BACKGROUND: Emerging confirmatory factor analytic (CFA) studies suggest that posttraumatic stress disorder (PTSD) as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is best characterized by seven factors, including re-experiencing, avoidance, negative affect, anhedonia, externalizing behaviors, and anxious and dysphoric arousal. The seven factors, however, have been found to be highly correlated, suggesting that one general factor may exist to explain the overall correlations among symptoms. METHODS: Using data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, a large, national survey of 36,309 U.S. adults ages 18 and older, this study proposed and tested an exploratory bifactor hybrid model for DSM-5 PTSD symptoms. The model posited one general and seven specific latent factors, whose associations with suicide attempts and mediating psychiatric disorders were used to validate the PTSD dimensionality. RESULTS: The exploratory bifactor hybrid model fitted the data extremely well, outperforming the 7-factor CFA hybrid model and other competing CFA models. The general factor was found to be the single dominant latent trait that explained most of the common variance (~76%) and showed significant, positive associations with suicide attempts and mediating psychiatric disorders, offering support to the concurrent validity of the PTSD construct. CONCLUSIONS: The identification of the primary latent trait of PTSD confirms PTSD as an independent psychiatric disorder and helps define PTSD severity in clinical practice and for etiologic research. The accurate specification of PTSD factor structure has implications for treatment efforts and the prevention of suicidal behaviors.

Treatment Utilization Among Adolescent Substance Users: Findings from the 2002 to 2013 National Survey on Drug Use and Health.

BACKGROUND: Adolescent substance users face serious health and social consequences and benefit from early diagnosis and treatment. The objectives of this study were to observe trends in treatment utilization; examine correlates of treatment utilization and treatment types/settings among adolescent substance users with and without substance use disorder (SUD); and assess gender differences. METHODS: National Survey on Drug Use and Health data were pooled across 2002 to 2013, with a combined sample of 79,885 past-year substance users ages 12 to 17 (17,510 with SUD and 62,375 without SUD). Treatment was defined as receiving treatment or counseling for use of alcohol or any drug, not counting cigarettes. Trends were assessed by joinpoint linear regression, and multivariable logistic regression assessed odds ratios of treatment utilization. RESULTS: Percentages of past-year treatment use did not change in 2002 to 2013. Treatment utilization was more prevalent among adolescents with SUD than without (11.4% vs. 1.4%) and among males than females. Among adolescents with and without SUD, criminal justice involvement and perceiving a need for treatment increased adolescent treatment utilization, while SUDs other than alcohol abuse, older age, and talking to parents increased treatment use among adolescents with SUD, and polysubstance use and male gender increased treatment among those without SUD. Treatment gaps persisted among non-Hispanic Blacks for both groups with and without SUD, male Hispanics with SUD, female non-Hispanic Asians without SUD, and private insurance coverages. Gender differences were observed in SUD, race/ethnicity, and insurance coverage. Most adolescents received treatment for both alcohol and drug use, and self-help group and outpatient rehabilitation facility were the most used treatment settings. CONCLUSIONS: Treatment utilization among adolescents with past-year substance use remained low and unimproved in 2002 to 2013. Treatment gaps among minority populations, insurance coverage, and in educating adolescents on seeking relevant treatment must be addressed. Using screening processes such as Screening, Brief Intervention, and Referral to Treatment, health professionals can help prevent lifelong SUD by recognizing and addressing substance misuse early.

Association of respondent psychiatric comorbidity with family history of comorbidity: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III.

OBJECTIVE: Substance use disorders and major psychiatric disorders are common, highly comorbid with each other, and familial. However, the extent to which comorbidity is itself familial remains unclear. The purpose of this study is to investigate associations between comorbidity among respondents with family history of comorbidity. METHODS: We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions-III to study the associations of family history (FH) of comorbidity among alcoholism, drug problems, depression, antisocial behavior, and anxiety disorders in parents and maternal and paternal grandparents with corresponding DSM-5 diagnostic comorbidity among respondents. We utilized multivariable multinomial logistic regression models controlling for age, sex, race, education, family income, marital status, and adverse childhood experiences (ACEs). RESULTS: All comorbid associations of any two disorders with FH were statistically significant; almost all adjusted odds ratios (ORs) for respondent comorbidity in the presence of FH of the parallel comorbidity exceeded 10. ORs involving antisocial behavior in relatives and antisocial personality disorder in respondents were consistently larger than those for any other pairs of disorders. After further adjustment for ACEs, most patterns of association were similar but the ORs were reduced twofold to threefold. ACEs may be mediators in relationships between familial and respondent comorbidities. CONCLUSION: Further investigations of relationships among familial comorbidity, ACEs, and respondents' diagnoses may improve understanding of comorbidity.

The epidemiology of DSM-5 posttraumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III.

OBJECTIVES: To present current, nationally representative US findings on the past-year and lifetime prevalences, sociodemographic correlates, psychiatric comorbidity, associated disability, and treatment of DSM-5 posttraumatic stress disorder (PTSD). METHODS: Face-to-face interviews with 36,309 adults in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. PTSD, alcohol and drug use disorders, and selected mood, anxiety, and personality disorders were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. RESULTS: Past-year and lifetime prevalences were 4.7 and 6.1 %, higher for female, white, Native American, younger, and previously married respondents, those with

Psychiatric disorders and mental health treatment in American Indians and Alaska Natives: results of the National Epidemiologic Survey on Alcohol and Related Conditions.

PURPOSE: To examine the prevalence of common psychiatric disorders and associated treatment-seeking, stratified by gender, among American Indians/Alaska Natives and non-Hispanic whites in the United States. Lifetime and 12-month rates are estimated, both unadjusted and adjusted for sociodemographic correlates. METHOD: Analyses were conducted with the American Indians/Alaska Native (n = 701) and Non-Hispanic white (n = 24,507) samples in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions [(NESARC) n = 43,093]. RESULTS: Overall, 70 % of the American Indian/Alaska Native men and 63 % of the women met criteria for at least one Diagnostic and Statistical Manual-IV lifetime disorder, compared to 62 and 53 % of Non-Hispanic white men and women, respectively. Adjusting for sociodemographic correlates attenuated the differences found. Nearly half of American Indians/Alaska Natives had a psychiatric disorder in the previous year; again, sociodemographic adjustments explained some of the differences found. Overall, the comparisons to non-Hispanic whites showed differences were more common among American Indian/Alaska Native women than men. Among those with a disorder, American Indian/Alaska Native women had greater odds of treatment-seeking for 12-month anxiety disorders. CONCLUSION: As the first study to provide national estimates, by gender, of the prevalence and treatment of a broad range of psychiatric disorders among American Indians/Alaska Natives, a pattern of higher prevalence of psychiatric disorder was found relative to Non-Hispanic whites. Such differences were more common among women than men. Prevalence may be overestimated due to cultural limitations in measurement. Unmeasured risk factors, some specific to American Indians/Alaska Natives, may also partially explain these results.

Psychiatric Symptom Clusters as Risk Factors for Alcohol Use Disorders in Adolescence: A National Study.

BACKGROUND: Few epidemiologic studies have examined a full range of adolescent psychiatric disorders in the general population. The association between psychiatric symptom clusters (PSCs) and DSM-IV alcohol use disorders (AUDs) among adolescents is not well understood. METHODS: This study draws upon the public-use data from the 2000 National Household Survey on Drug Abuse, including a study sample of 19,430 respondents aged 12 to 17. Logistic regression and exploratory structural equation modeling assess the associations between PSCs and DSM-IV AUDs by gender. The PSCs are based on brief screening scales devised from the Diagnostic Interview Schedule for Children Predictive Scales. RESULTS: Several PSCs were found to be significantly associated with DSM-IV AUDs, including separation anxiety, generalized anxiety, depression, oppositional defiant disorder, and conduct disorder among both genders, and panic disorder and obsessive/ compulsive disorder among females. Consistent with the literature, the analysis of PSCs yields 3 factors identical for both genders-2 internalizing factors (fear and anxiety-misery) and 1 externalizing factor. Adolescents who scored higher on the externalizing factor tended to have higher levels of the AUD factor. Female adolescents who scored higher on the internalizing misery factor and lower on the internalizing fear factor also tended to have higher levels of the AUD factor. CONCLUSIONS: The associations that we found between PSCs and AUDs among adolescents in this study are consistent with those found among adults in other studies, although gender may moderate associations between internalizing PSCs and AUDs. Our findings lend support to previous findings on the developmentally stable associations between disruptive behaviors and AUDs among adolescents as well as adults in the general population.

Childhood adversity moderates the effect of ADH1B on risk for alcohol-related phenotypes in Jewish Israeli drinkers.

Childhood adversity and genetic variant ADH1B-rs1229984 have each been shown to influence heavy alcohol consumption and disorders. However, little is known about how these factors jointly influence these outcomes. We assessed the main and additive interactive effects of childhood adversity (abuse, neglect and parental divorce) and the ADH1B-rs1229984 on the quantitative phenotypes 'maximum drinks in a day' (Maxdrinks) and DSM-Alcohol Use Disorder (AUD) severity, adjusting for demographic variables, in an Israeli sample of adult household residents (n = 1143) evaluated between 2007 and 2009. Childhood adversity and absence of the protective ADH1B-rs1229984 A allele were associated with greater mean Maxdrinks (mean differences: 1.50; 1.13, respectively) and AUD severity (mean ratios: 0.71; 0.27, respectively). In addition, childhood adversity moderated the ADH1B-rs1229984 effect on Maxdrinks (P < 0.01) and AUD severity (P < 0.05), in that there was a stronger effect of ADH1B-rs1229984 genotype on Maxdrinks and AUD severity among those who had experienced childhood adversity compared with those who had not. ADH1B-rs1229984 impacts alcohol metabolism. Therefore, among those at risk for greater consumption, e.g. those who experienced childhood adversity, ADH1B-rs1229984 appears to have a stronger effect on alcohol consumption and consequently on risk for AUD symptom severity. Evidence for the interaction of genetic vulnerability and early life adversity on alcohol-related phenotypes provides further insight into the complex relationships between genetic and environmental risk factors.

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings.

PURPOSE: The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking. METHOD: NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized. RESULT: The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers. CONCLUSIONS: Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.

Childhood maltreatment, stressful life events, and alcohol craving in adult drinkers.

BACKGROUND: Little is known about the relationship between stressful life events and alcohol craving in the general population, and whether a history of childhood maltreatment sensitizes individuals to crave alcohol after adult stressors. METHODS: Participants were 22,147 past-year drinkers from Wave 2 (2004 to 2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. A structured, face-to-face interview assessed past-year stressful life events, alcohol craving, and history of childhood maltreatment. Logistic regression was used to generate adjusted odds ratios (aOR) to evaluate the relationship between stressful life events and craving, adjusting for demographic characteristics and parental history of alcoholism. Interaction between stressful life events and childhood maltreatment was also assessed. RESULTS: Compared to participants with no stressful life events, those with ≥ 3 events had increased odds of moderate alcohol craving (aOR = 3.15 [95% CI = 2.30 to 4.33]) and severe craving (aOR = 8.47 [95% CI = 4.78 to 15.01]). Stressful life events and childhood maltreatment interacted in predicting severe craving (p = 0.017); those with ≥ 3 events were at higher risk of craving if they had been exposed to childhood maltreatment. CONCLUSIONS: A direct relationship between stressful life events and risk of alcohol craving was observed. Further, history of childhood maltreatment increased the salience of stressful life events in adulthood. Future studies should examine the role of psychiatric comorbidity in more complex models of stress sensitization and alcohol craving.

Personality disorders and the persistence of anxiety disorders in a nationally representative sample.

BACKGROUND: Among individuals with anxiety disorders, comorbid personality disorders (PDs) increase cross-sectional symptom severity and decrease functioning. Little is known, however, about how PDs influence the course of anxiety disorders over time. The purpose of this study was to examine the effect of PDs on the persistence of four anxiety disorders in a nationally representative sample in the United States. METHODS: Two waves of data were collected on 34,653 participants, 3 years apart. At both waves, participants were evaluated for generalized anxiety disorder (GAD), social and specific phobias, and panic disorder. Predictors of persistence included all DSM-IV PDs. Control variables included demographics, comorbid PDs, age at onset of the anxiety disorder, number of prior episodes, duration of the current episode, treatment history, and cardinal symptoms of exclusionary diagnoses for each anxiety disorder. RESULTS: Any PD, two or more PDs, borderline PD, schizotypal PD, mean number of PD criteria met, and mean number of PDs diagnosed predicted the persistence of all four anxiety disorders. Narcissistic PD predicted persistence of GAD and panic disorder. Schizoid and avoidant PDs also predicted persistence of GAD. Finally, avoidant PD predicted persistence of social phobia. Particular patterns of cross-cluster PD comorbidity were strong predictors of the persistence of individual anxiety disorders as well. CONCLUSIONS: In this national sample, a variety of PDs robustly predicted the persistence of anxiety disorders over 3 years, consistent with the results of recent prospective clinical studies. Personality psychopathology should be assessed and addressed in treatment for all patients with anxiety disorders.

Trauma exposure, posttraumatic stress disorder and risk for alcohol, nicotine, and marijuana dependence in Israel.

BACKGROUND: Substance dependence is more common among trauma-exposed individuals; however, most studies suggest that Posttraumatic Stress Disorder (PTSD) accounts for the link between trauma exposure (TE) and substance dependence. OBJECTIVES: This study examined associations between TE and substance dependence (alcohol, nicotine, and marijuana), and whether PTSD accounted for this association. METHOD: 1317 Jewish Israeli household residents completed in-person structured interviews assessing TE, PTSD, and substance (alcohol, nicotine, marijuana) dependence between 2007 and 2009. Regression analyses examined associations among TE, PTSD, and substance dependence. RESULTS: In the full sample, mean number of traumatic events was 2.7 (sd=2.2), with 83.7% experiencing at least one event. In the full sample, mean number of PTSD symptoms was 2.5 (sd=3.4), with 13.5% meeting PTSD diagnostic criteria. Prevalence of alcohol dependence was 13.4%; nicotine dependence 52.8%; and marijuana dependence 12.1%. Number of traumatic events was associated with increased odds of alcohol (OR=1.3; 95% CI=1.2-1.4) and nicotine (OR=1.2; 95% CI=1.1-1.3) dependence. Similarly, any traumatic event exposure was associated with increased odds of alcohol (OR=3.1; 95% CI=1.6-6.0) and nicotine (OR=1.9; 95% CI=1.2-2.9) dependence. PTSD symptoms were associated with increased odds of alcohol (OR=1.2; 95% CI=1.1-1.3), nicotine (OR=1.1; 95% CI=1.1-1.2), and marijuana (OR=1.1; 95% CI=1.04-1.2) dependence; similarly, a PTSD diagnosis was associated with increased odds of alcohol (OR=3.4; 95% CI=2.1-5.5), nicotine (OR=2.2; 95% CI=1.4-3.4), and marijuana (OR=2.6; 95% CI=1.2-5.9) dependence. PTSD symptoms accounted for a sizeable proportion of the TE effect on alcohol (46%) and nicotine dependence (31%). CONCLUSION: Individuals with more traumatic events had heightened risk for alcohol and nicotine dependence, and PTSD symptoms partially accounted for this risk. However, marijuana dependence was only significantly related to PTSD symptoms. Clinicians and researchers should separately assess different types of dependence among trauma-exposed individuals both with and without PTSD symptoms.

An overview of and rationale for changes proposed for pathological gambling in DSM-5.

The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is scheduled for publication in 2013. It will include several changes to the diagnosis of pathological gambling: the name of the disorder will be altered, the threshold for diagnosis will decrease, and one criterion will be removed. This paper reviews the rationale for these changes and addresses how they may impact diagnosis and treatment of the disorder, as well as potential for future research in the field.

Substance-use disorders and poverty as prospective predictors of first-time homelessness in the United States.

OBJECTIVES: We examined whether substance-use disorders and poverty predicted first-time homelessness over 3 years. METHODS: We analyzed longitudinal data from waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions to determine the main and interactive effects of wave 1 substance use disorders and poverty on first-time homelessness by wave 2, among those who were never homeless at wave 1 (n = 30,558). First-time homelessness was defined as having no regular place to live or having to live with others for 1 month or more as a result of having no place of one's own since wave 1. RESULTS: Alcohol-use disorders (adjusted odds ratio [AOR] = 1.34), drug-use disorders (AOR = 2.51), and poverty (AOR = 1.34) independently increased prospective risk for first-time homelessness, after adjustment for ecological variables. Substance-use disorders and poverty interacted to differentially influence risk for first-time homelessness (P < .05), before, but not after, adjustment for controls. CONCLUSIONS: This study reinforces the importance of both substance-use disorders and poverty in the risk for first-time homelessness, and can serve as a benchmark for future studies. Substance abuse treatment should address financial status and risk of future homelessness.

Differences in the profiles of DSM-IV and DSM-5 alcohol use disorders: implications for clinicians.

BACKGROUND: Existing information on consequences of the DSM-5 revision for the diagnosis of alcohol use disorders (AUD) has gaps, including missing information critical to understanding implications of the revision for clinical practice. METHODS: Data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were used to compare AUD severity, alcohol consumption and treatment, sociodemographic and health characteristics, and psychiatric comorbidity among individuals with DSM-IV abuse versus DSM-5 moderate AUD and DSM-IV dependence versus DSM-5 severe AUD. For each pair of disorders, we additionally compared 3 mutually exclusive groups: individuals positive solely for the DSM-IV disorder, those positive solely for the DSM-5 disorder, and those positive for both. RESULTS: Whereas 80.5% of individuals positive for DSM-IV dependence were positive for DSM-5 severe AUD, only 58.0% of those positive for abuse were positive for moderate AUD. The profiles of individuals with DSM-IV dependence and DSM-5 severe AUD were almost identical. The only significant (p < 0.005) difference, more AUD criteria among the former, reflected the higher criterion threshold (≥ 4 vs. ≥ 3) for severe AUD relative to dependence. In contrast, the profiles of individuals with DSM-5 moderate AUD and DSM-IV abuse differed substantially. The former endorsed more AUD criteria, had higher rates of physiological dependence, were less likely to be White individuals and men, had lower incomes, were less likely to have private and more likely to have public health insurance, and had higher levels of comorbid anxiety disorders than the latter. CONCLUSIONS: Similarities between the profiles of DSM-IV and DSM-5 AUD far outweigh differences; however, clinicians may face some changes with respect to appropriate screening and referral for cases at the milder end of the AUD severity spectrum, and the mechanisms through which these will be reimbursed may shift slightly from the private to public sector.

Other- and self-directed forms of violence and their relationships to DSM-IV substance use and other psychiatric disorders in a national survey of adults.

OBJECTIVE: To examine associations between DSM-IV psychiatric disorders and other- and self-directed violence in the general population. METHODS: Data were obtained from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 & 2 (n=34,653). Four violence categories were derived from a latent class analysis (LCA) of 5 other-directed and 4 self-directed violent behavior indicators. Multinomial logistic regression examined class associations for gender, race-ethnicity, age and DSM-IV substance use, mood, anxiety, and personality disorders. RESULTS: Approximately 16% of adults reported some form of violent behavior distributed as follows: other-directed only, 4.6%; self-directed only, 9.3%; combined self- and other-directed, 2.0%; and no violence, 84.1%. The majority of the DSM-IV disorders included in this study were significantly and independently related to each form of violence. Generally, other-directed violence was more strongly associated with any substance use disorders (81%) and any personality disorders (42%), while self-directed violence was more strongly associated with mood (41%) and anxiety disorders (57%). Compared with these two forms of violence, the smaller group with combined self- and other-directed violence was more strongly associated with any substance use disorders (88%), mood disorders (63%), and personality disorders (76%). CONCLUSION: Findings from this study are consistent with recent conceptualizations of disorders as reflecting externalizing disorders and internalizing disorders. The identification of the small category with combined forms of violence further extends numerous clinical studies which established associations between self- and other-directed violent behaviors. The extent to which the combined violence category represents a meaningful and reliable category of violence requires further detailed studies.

Temporal associations between physical illnesses and mental disorders--results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

Clinical and epidemiologic evidence has documented the significant associations between medical illnesses and psychiatric disorders. However, extensive research has focused on the comorbidity of medical conditions and depression, and most were cross sectional, focused on clinical samples, and grounded in DSM-III or DSM-III-R diagnostic criteria. The current prospective investigation examined associations among medical conditions at baseline and incident psychiatric disorders over a 3-year follow-up, using data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Overall, the 3-year incidence rates of DSM-IV substance use, mood and anxiety disorders ranged from 0.65% (bipolar II) to 5.2% (alcohol abuse). Multiple regression analysis was conducted to examine the prospective physical-mental associations, while controlling for sociodemographic characteristics, psychological stress and health-related risk factors, and comorbid physical and psychiatric disorders. The present study represents, to our knowledge the largest population-based prospective study examining the physical-mental associations. Our results showed distinctly different patterns of comorbidity of medical illnesses with substance use, mood, and anxiety disorders. Stomach ulcer/gastritis, hypertension and arthritis emerged to be significant predictors of incident psychiatric disorders.