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CORK Bibliography: Substance Use and Anxiety Disorders

46 citations. January 2009 to present

Prepared: September 2012

Bacon AK; Ham LS. Attention to social threat as a vulnerability to the development of comorbid social anxiety disorder and alcohol use disorders: An avoidance-coping cognitive model. Addictive Behaviors 35(11): 925-939, 2010. (137 refs.)

Despite the frequent comorbidity of social anxiety disorder and alcohol use disorders, no theoretical model currently exists to explain the specific mechanisms underlying the comorbidity between these two disorders. An integration of existing theoretical models and empirical evidence across the social anxiety and alcohol use literatures is presented as the Avoidance-Coping Cognitive Model, which proposes that socially anxious individuals may be particularly vulnerable to the anxiolytic effects of alcohol through reductions in attention biases to social threat. The disproportionate reduction in anxiety may then make alcohol an attractive method of avoidance coping. Gaps in the empirical literature are reviewed in light of this model as future directions are suggested.

Baigent M. Managing patients with dual diagnosis in psychiatric practice. (review). Current Opinion in Psychiatry 25(3): 201-205, 2012. (24 refs.)

Purpose of review: To focus on recent research that may influence clinical practice in relation to patients with dual diagnosis disorders. Recent findings: Harmful substance use is a heightened risk with bipolar disorder. Self-medication with substances of abuse for anxiety is linked with greater risk of developing anxiety disorders, particularly social anxiety disorder. Antisocial and schizotypal personality disorders were particularly linked with chronicity in substance use disorders. There are sex differences in responses to psychological approaches for dual disorders involving alcohol. Integrated dual diagnosis treatment for youth is not conclusive but shows promise. Online therapy is viable for adult patients with dual diagnosis. Structured interventions reduce the risk of opioid misuse amongst those with chronic pain, who are identified as at high risk. Summary: We have confirmation that clinicians should be particularly vigilant in monitoring for substance use problems early in anxiety disorders and mood disorders and that certain personality disorders are linked with substance use chronicity. Practitioners can incorporate specific therapy approaches for dual disorders that appear to have advantages over treatment as usual.

Bella TT; Omigbodun OO. Social phobia in Nigerian university students: Prevalence, correlates and co-morbidity. Social Psychiatry and Psychiatric Epidemiology 44(6): 458-463, 2009. (26 refs.)

Background: Social phobia is considered to be among the most common anxiety disorders. Despite its early onset, chronic course, disability and co-morbidity there is virtually no information about this disorder in young people in sub-Saharan Africa. Objectives The prevalence, correlates, and co-morbidity of social phobia in a Nigerian undergraduate university population were determined. Methods A cross-sectional survey of students at the University of Ibadan was carried out. Instruments used were the Composite International Diagnostic Interview (CIDI), the Alcohol Use Identification Test, the General Health Questionnaire and the WHO-Disability Assessment Schedule. Results The lifetime and 12-month prevalence of social phobia were 9.4 and 8.5% respectively. On bivariate analysis, social phobia was significantly associated with lifetime and 12-month depression, psychological distress and reporting poor overall health (P < 0.05). Lifetime depression, psychological distress and perceived poor overall health remained strongly and independently associated with social phobia after regression analysis. Conclusion: The prevalence of social phobia among Nigerian university students is similar to what has been found in other parts of the world. There is a need for increased awareness of this disorder and its association with depression so that sufferers can receive early treatment to prevent long-term disability.

Bornovalova MA; Gratz KL; Levy R; Lejuez CW. Understanding the heterogeneity of BPD symptoms through latent class analysis: Initial results and clinical correlates among inner-city substance users. Psychological Assessment 22(2): 233-245, 2010. (75 refs.)

The current study investigated the heterogeneity of borderline personality disorder (BPD) symptoms in a sample of 382 inner-city, predominantly African American male substance users through the use of latent class analysis. A 4-class model was statistically preferred, with 1 class interpreted to be a baseline class. I class interpreted to be a high-BPD class, and 2 classes interpreted as intermediate classes. As a secondary goal, we examined the resulting BPD classes with respect to relevant clinical correlates, including temperamental vulnerabilities (affective instability, impulsivity, and interpersonal instability), childhood emotional abuse, drug choice, and co-occurring mood and anxiety disorders. The high-BPD class evidenced the highest levels of the temperamental vulnerabilities and environmental stressors. the baseline class evidenced the lowest levels, and the 2 intermediate classes fell in between. In addition, the high-BPD class had a higher probability of cocaine and alcohol dependence, as well as mood and anxiety disorders, than did the baseline class. Rates of alcohol use and mood disorders for the intermediate classes fell in between the high-BPD and the baseline classes. Results are discussed in relation to the current diagnostic conceptualization of BPD.

Buckner JD; Heimberg RG; Schneier FR; Liu SM; Wang S; Blanco C. The relationship between cannabis use disorders and social anxiety disorder in the National Epidemiological Study of Alcohol and Related Conditions (NESARC). Drug and Alcohol Dependence 124(1-2): 128-134, 2012. (38 refs.)

Background: Cannabis use disorders (CUD) are highly comorbid with social anxiety disorder (SAD), and SAD may be a risk factor for cannabis dependence. This study explored these relationships in several ways. First, we examined whether SAD was more likely to be related to cannabis dependence than abuse. Second, we examined the temporal relations between CUD and SAD. Third, we examined whether SAD was related to faster transition from age of first cannabis use to CUD onset relative to other anxiety disorders. Fourth, we tested whether having both disorders was associated with greater impairment and psychiatric comorbidity. Method: The sample consisted of adults from Wave 1 of the National Epidemiological Survey on Alcohol and Related Conditions, 2957 of whom had CUD and no SAD, 1643 had SAD and no CUD, and 340 had CUD-SAD. Results: SAD was more likely to be related to cannabis dependence than abuse. This relation remained after controlling for race, sex, and some other psychiatric disorders (including some anxiety disorders). Age-of-onset data suggest SAD onset prior to CUD onset for most CUD-SAD respondents. CUD-SAD was related to greater impairment and psychiatric comorbidity than either disorder alone. Conclusions: Although SAD is related to CUD, it has a stronger association with cannabis dependence than abuse. This link is not better accounted for by other psychopathology measured in this study. SAD onset prior to CUD for the majority of CUD-SAD respondents. Importantly, the co-occurrence of these two disorders appears to result in greater impairment and distress than either disorder alone.

Buckner JD; Schmidt NB. Social anxiety disorder and marijuana use problems: The mediating role of marijuana effect expectancies. Depression and Anxiety 26(9): 864-870, 2009. (45 refs.)

Background: Individuals with social anxiety disorder (SAD) appear particularly vulnerable to marijuana-related problems. Yet, mechanisms underlying this association are unclear. Methods: This study examined the role of marijuana effect expectancies in the relation between SAD and marijuana problems among 107 marijuana users (43.0% female), 26.2% of whom met Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition criteria for SAD. Anxiety and mood disorders were determined during clinical interviews using the Anxiety Disorders Interview Schedule-IV-L (ADIS-IV). Results: Analyses (including sex, marijuana use frequency, major depressive disorder, and other anxiety disorders) suggest that SAD was the only disorder significantly associated with past 3-month marijuana problems. Compared to those without SAD, individuals with SAD were more likely to endorse the following marijuana expectancies: cognitive/behavioral impairment and global negative expectancies. Importantly, these expectancies mediated the relations between SAD status and marijuana problems. Conclusions: These data support the contention that SAD is uniquely related to marijuana problems and provide insight into mechanisms underlying this vulnerability.

Buckner JD; Turner RJ. Social anxiety disorder as a risk factor for alcohol use disorders: A prospective examination of parental and peer influences. Drug and Alcohol Dependence 100(1-2): 128-137, 2009. (75 refs.)

Elucidation of mechanisms underlying the high rates of alcohol use disorder (AUD) remains a pressing clinical and research concern. Despite data indicating that social anxiety disorder (SAD) maybe a psychological vulnerability that increases AUD risk, no known prospective research has examined underlying mechanisms. Given the nature of SAD, social support and peer alcohol use may be implicated. The present study set out to clarify the SAD-AUD link in several ways using a prospective dataset comprised of 1803 (47% female) young adults at T1, 1431 of whom were assessed again approximately 3 years later. First, stringent criteria were used to directly test whether SAD was a risk for AUD. Second, we examined whether social support and peer alcohol use moderated the prospective SAD-AUD link. Structured diagnostic interviews were conducted to assess DSM-IV Axis I disorders, negative life events, social support, and peer alcohol use. Among men, Time 1 (T1) SAD was not significantly related to Time 2 (T2) AUD. Yet, among women, T1 SAD was related to T2 AUD. Further, T1 SAD was the only internalizing disorder to significantly predict T2 AUD after controlling for relevant variables (e.g., T1 depression, other anxiety, alcohol and marijuana use disorders). The SAD-AUD relation demonstrated directional specificity. Family cohesion and adverse family relations significantly moderated this relation. Findings highlight the important role of SAD and familial support in the onset of AUD among women.

Chen KW; Berger CC; Forde DP; D'Adamo C; Weintraub E; Gandhi D. Benzodiazepine use and misuse among patients in a methadone program. BMC Psychiatry 11(e-article 90), 2011. (27 refs.)

Background: Benzodiazepines (BZD) misuse is a serious public health problem, especially among opiate-dependent patients with anxiety enrolled in methadone program because it puts patients at higher risk of life-threatening multiple drug overdoses. Both elevated anxiety and BZD misuse increase the risk for ex-addicts to relapse. However, there is no recent study to assess how serious the problem is and what factors are associated with BZD misuse. This study estimates the prevalence of BZD misuse in a methadone program, and provides information on the characteristics of BZD users compared to non-users. Methods: An anonymous survey was carried out at a methadone program in Baltimore, MD, and all patients were invited to participate through group meetings and fliers around the clinic on a voluntary basis. Of the 205 returned questionnaires, 194 were complete and entered into final data analysis. Those who completed the questionnaire were offered a $5 gift card as an appreciation. Results: 47% of the respondents had a history of BZD use, and 39.8% used BZD without a prescription. Half of the BZD users (54%) started using BZD after entering the methadone program, and 61% of previous BZD users reported increased or resumed use after entering methadone program. Compared to the non-users, BZD users were more likely to be White, have prescribed medication for mental problems, have preexistent anxiety problems before opiate use, and had anxiety problems before entering methadone program. They reported more mental health problems in the past month, and had higher scores in anxiety state, depression and perceived stress (p < .05). Conclusions: Important information on epidemiology of BZD misuse among methadone-maintenance patients suggests that most methadone programs do not address co-occurring anxiety problems, and methadone treatment may trigger onset or worsening of BZD misuse. Further study is needed to explore how to curb misuse and abuse of BZD in the addiction population, and provide effective treatments targeting simultaneously addiction symptoms, anxiety disorders and BZD misuse.

Chisolm MS; Tuten M; Brigham EC; Strain EC; Jones HE. Relationship between cigarette use and mood/anxiety disorders among pregnant methadone-maintained patients. American Journal on Addictions 18(5): 422-429, 2009. (61 refs.)

This study investigates the association between cigarette use and current mood/anxiety disorders among pregnant opioid-dependent patients. Pregnant methadone-maintained women (N = 122) completed the Addiction Severity Index and Structured Clinical Interview for DSM-IV. Participants were categorized based on past 30 days cigarette use: no (n = 15) and any smoking (n = 107); this latter group was then subdivided into light (one to ten cigarettes/day; n = 55), and heavy smokers (11+cigarettes/day; n=52). Any smoking was significantly associated with any current mood/anxiety disorder (p < 0.001), any current mood disorder (p = 0.007), and any current anxiety disorder (p<0.001). No significant association was found between specific level of cigarette use and mood/anxiety disorders. This association between smoking and psychiatric disorders has implications for the mental and physical health of methadone-maintained women and their children, and may contribute to the understanding of the physiological mechanisms underlying smoking and nicotine dependence.

Chou KL; Mackenzie CS; Liang K; Sareen J. Three-year incidence and predictors of first-onset of dsm-iv mood, anxiety, and substance use disorders in older adults: Results from wave 2 of the national epidemiologyogic survey on alcohol and related conditions. Journal of Clinical Psychiatry 72(2): 144-155, 2011. (90 refs.)

Objective: The aim of this study was to determine the incidence rates of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mood disorders, anxiety disorders, and substance use disorders in older adults and to identify sociodemographic, psychopathological, health-related, and stress-related predictors of onset of these disorders. Method: A nationally representative sample of 8,012 community-dwelling adults aged 60 and above was interviewed twice over a period of 3 years, in 2000-2001 and 2004-2005. First incidence of mood, anxiety, and substance use disorders was assessed over a period of 3 years using the Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV Version. Results: The 3-year incidence rates of DSM-IV mood, anxiety, and substance use disorders were highest for nicotine dependence (3.38%) and major depressive disorder ([MDD] 3.28%) and lowest for drug use disorder (0.29%) and bipolar II disorder (0.34%). Incidence rates were significantly greater among older women for MDD (99% CI, 1.22-3.13) and generalized anxiety disorder (GAD; 99% CI, 1.20-4.26) and greater among older men for nicotine dependence and alcohol abuse and dependence. Posttraumatic stress disorder predicted incidence of MDD, bipolar I disorder, panic disorder, specific phobia, and GAD, while Cluster B personality disorders predicted incident MDD, bipolar I and II disorders, panic disorder, social phobia, GAD, nicotine dependence, and alcohol dependence. Poor self-rated health increased the risk for the onset of MDD, whereas obesity decreased the incidence of nicotine dependence. Conclusions: Information about disorders that are highly incident in late life and risk factors for the onset of psychiatric disorders among older adults are important for effective early intervention and prevention initiatives.

Chou SP; Lee HK; Cho MJ; Park JI; Dawson DA; Grant BF. Alcohol use disorders, nicotine dependence, and co-occurring mood and anxiety disorders in the United States and South Korea: A cross-national comparison. Alcoholism: Clinical and Experimental Research 36(4): 654-662, 2012. (41 refs.)

Background: The strong comorbidity between substance use disorders (SUDs) and mood and anxiety disorders has been well documented. In view of lack of research findings addressing the co-occurrence of SUDs and mood and anxiety disorders, this study examined the pattern of comorbidity of alcohol use disorders (AUDs) and nicotine dependence (ND) between 2 culturally diverse countries, the United States and South Korea. Methods: Using the nationally representative samples of the U. S. and Korean general populations, we directly compared rates and comorbidity patterns of AUDs, ND, and mood and anxiety disorders between the 2 countries. We further examined the rates and the comorbidity pattern among individuals with AUDs who sought treatment in the last 12 months. Twelve-month prevalence rates were derived to estimate country differentials, and odds ratios (ORs) and 95% confidence intervals were estimated to measure the strength of comorbid associations while adjusting for all sociodemographic characteristics in multivariate logistic models specific to each country. Results: The 12-month prevalence rates of AUDs, ND, and any mood disorder and any anxiety disorder were 9.7, 14.4, 9.5, and 11.9% among Americans, whereas the corresponding rates were 7.1, 6.6, 2.0, and 5.2% among Koreans. These rates were significantly greater (except for any AUD) among Americans than among their Korean counterparts. With respect to comorbidity, both countries showed comparable patterns that the prevalence rates of mood and anxiety disorders were consistently the highest among persons with alcohol dependence (AD). Also, a disparate pattern was observed in Korea that the prevalence rates of mood and anxiety disorders were generally lower among individuals with ND than among those with alcohol abuse and AD. Furthermore, despite significantly greater prevalence of AD in Korea (5.1%) than in the United States (4.4%), alcohol-dependent Americans were 4 times (OR = 3.93) more likely to seek treatment compared to their Korean counterparts. Conclusions: Our results indicated that the prevalence of AD in Korea was substantially greater than that in both Western and other Asian countries, suggesting a maladaptive pattern of alcohol use in Korea, which is different from the general use pattern of other East Asian countries. The low rate of treatment utilization among Koreans might be attributable to perceived social stigma toward SUDs or mental health problems despite the fact that the Korean government offers national health insurance.

Cougle JR; Zvolensky MJ; Fitch KE; Sachs-Ericsson N. The role of comorbidity in explaining the associations between anxiety disorders and smoking. Nicotine & Tobacco Research 12(4): 355-364, 2010. (52 refs.)

Research has generally found strong associations between smoking and anxiety disorders. The present study sought to examine the role of comorbidity in explaining these relationships. Participants from the National Comorbidity Survey-Replication (N = 5,692) were included in the present study. Axis I disorders were assessed using the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview. In addition, smoking and mental health treatment history were assessed. Multivariate analyses covarying for demographic variables and psychiatric and substance use comorbidity found that posttraumatic stress disorder was uniquely associated with every smoking outcome of interest, including 12-month and lifetime daily and heavy smoking, nicotine dependence, and cessation failure. Generalized anxiety disorder and social anxiety disorder were associated with fewer smoking-related outcomes, and contrary to predictions, panic disorder was only independently associated with 12-month daily smoking. Panic attack history, however, was uniquely associated with 12-month daily and heavy smoking, nicotine dependence, and lifetime cessation failure. In addition, analyses indicated that greater number of anxiety disorders was associated with greater prevalence of each smoking outcome, and the presence of even one anxiety disorder was associated with elevated smoking prevalence. Several specific anxiety disorders were found to be uniquely associated with smoking behavior. Findings suggest that comorbidity may only explain the associations with smoking difficulties for some anxiety disorders.

Daradkeh F; Moselhy HF. Death anxiety (Thanatophobia) among drug dependents in an Arabic psychiatric hospital. American Journal of Drug and Alcohol Abuse 37(3): 184-188, 2011. (30 refs.)

Aim: The primary aim of this study was, for the first time to our knowledge, to examine the level of death anxiety (thanatophobia) in drug dependents attending the outpatient clinic in a psychiatric hospital and to examine the relationship of demographic variables to death anxiety. Method: Eighty-five patients were recruited from outpatient psychiatric attendees at the psychiatric hospital, Kingdom of Bahrain. The death anxiety scale was administered to assess death anxiety, and a clinical psychiatric interview was used to assess psychopathology. Results: The mean age of the sample was 36.8 years (SD = 8.8). All subjects who participated in the study were Arabic males; the majority of them were primary school (i.e. first 5 years of education or schooling) educated (n = 57; 67%) and single (n = 48; 56.5%). The total mean of death anxiety score of the drug abusers was high (3.52 +/- .95). One-way ANOVA showed that there was no significant difference among the scores the drug dependents received on the death anxiety scale related to different groups of age, education, type of the drug used, or the number of times of taking drugs per day. However, there was a significant difference in the level of control of use, marital status, duration of use, cigarettes smoking, and level of religiosity. Conclusion: The results of this study indicate that the level of death anxiety is high, in general, among drug abusers and that being divorced, not actively practicing a religious faith, having at least 1-10 years or more than 20 years history of drug abuse, and smoking at least 20 or more cigarettes per day significantly increases the level of death anxiety.

Evren C; Sar V; Dalbudak E; Oncu F; Cakmak D. Social anxiety and dissociation among male patients with alcohol dependency. Psychiatry Research 165(3): 273-280, 2009. (56 refs.)

The aim of this study was to investigate the relationship between social anxiety and dissociation among male patients with alcohol dependency. Participants were 176 male patients consecutively admitted to an alcohol dependency treatment unit. The Liebowitz Social Anxiety Scale, the Dissociative Experiences Scale, the Beck Depression Inventory, the Spielberger State and Trait Anxiety Inventory, the Michigan Alcoholism Screening Test, and the Symptom Checklist-90-Revised were administered to all participants. The dissociative (N=58, 33.0%) group had significantly higher social anxiety scores than the non-dissociativc participants. Patients with a history of suicide attempt or childhood abuse had elevated social anxiety scores compared to those without. In multivariate analysis, dissociative taxon membership predicted both of the two social anxiety subscale scores consisting of fear/anxiety and avoidance in a highly significant level while trait anxiety was a significant covariant for these subscales. Among dissociative symptoms, only depersonalization and amnesia/fugue were predictors of social anxiety. Dissociation and social anxiety are interrelated among alcohol-dependent men. This relationship may have implications for prevention and treatment of alcohol dependency among men with a childhood trauma history in particular.

Farris SG; Epstein EE; McCrady BS; Hunter-Reel D. Do co-morbid anxiety disorders predict drinking outcomes in women with alcohol use disorders? Alcohol and Alcoholism 47(2): 143-148, 2012. (33 refs.)

Aims: It is unclear whether co-morbid anxiety disorders predict worse drinking outcomes during attempts to change drinking behavior. Studies have yielded mixed results, and have rarely examined drinking outcomes based on a specific type of anxiety disorder. Women with alcohol use disorders (AUDs) are of particular interest as they are at risk for co-morbid anxiety [Kessler et al. (1997) Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the national co-morbidity survey. Arch General Psychiatry 54:313-21]. Methods: Participants were 260 women with AUDs participating in an alcohol-treatment outcome studies. The Timeline Follow-Back was used to assess drinking frequency (percent days drinking) prior, within and 6 months post-treatment. The current study tested the hypothesis that having at least one lifetime anxiety disorder diagnosed at baseline using the Structured Clinical Interview for DSM Disorders would be associated with more drinking at all study time points. Exploratory analyses examined patterns of drinking outcomes by specific anxiety diagnoses. Results: Lifetime anxiety diagnosis was linked to poorer drinking outcomes post-treatment (beta = 0.15, P = 0.020), despite less frequent drinking prior to treatment. Analyses by specific anxiety diagnosis indicated that generalized anxiety disorder predicted poorer drinking outcomes within treatment (beta = 0.14, P = 0.018) and during follow-up (beta = 0.16, P = 0.014). Conclusion: Co-morbid anxiety problems complicate treatment for AUDs among women. Further, specific anxiety disorders should be evaluated as distinct constructs as evidenced by the differential outcomes related to generalized anxiety disorder. Implications for treatment development for women with AUDs are discussed.

Fenton MC; Keyes KM; Martins SS; Hasin DS. The role of a prescription in anxiety medication use, abuse, and dependence. American Journal of Psychiatry 167(10): 1247-1253, 2010. (34 refs.)

Objective: Prescriptions for anxiety medications have increased substantially in recent years. Individuals with anxiety disorders are at risk of nonmedical use of these medications, but information about whether this risk is elevated among patients with a prescription for such medications is lacking. The authors compared risk of nonmedical use in individuals in a national sample with and without a prescription for anxiety medication and identified characteristics associated with nonmedical use. Method: Data were drawn from face-to-face surveys of 34,653 adult participants in the National Epidemiologyogic Survey on Alcohol and Related Conditions. The risk of nonmedical use of prescription anxiety medication and associated drug use disorders was computed for individuals who had or had not ever received a prescription for anxiety medication; among those who had received a prescription, characteristics associated with nonmedical use were analyzed. Results: Prescription of anxiety medication was associated with lifetime and past-year nonmedical use (odds ratios, 1.6 and 1.9, respectively) and lifetime DSM-IV abuse or dependence (odds ratio, 2.6). Among respondents who received a prescription (N = 4,294), nonmedical use was associated with male sex, younger age, white race, history of use of illicit drugs, history of other drug use disorders, and history of illegal behaviors. Conclusions: These results indicate that prescription for anxiety medications is associated with nonmedical use of these medications, although the direction of causality cannot be determined in this study. Although anxiety medications have clinical utility, greater clinical attention should be given to the potential for their abuse among patients at particular risk.

Gao K; Kemp DE; Conroy C; Ganocy SJ; Findling RL; Calabrese JR. Comorbid anxiety and substance use disorders associated with a lower use of mood stabilisers in patients with rapid cycling bipolar disorder: A descriptive analysis of the cross-sectional data of 566 patients. International Journal of Clinical Practice 64(3): 336-344, 2010. (52 refs.)

Objective: To study mood stabiliser treatment in patients with bipolar disorder with or without anxiety disorders (ADs) and/or substance use disorders (SUDs). Methods: Extensive clinical interview and Mini-International Neuropsychiatric Interview were used to ascertain DSM-IV diagnoses of rapid cycling bipolar I (RCBDI) or II (RCBDII), SUDs and ADs. Previous treatment statuses with a mood stabiliser after the first onset of mania/hypomania (unmedicated, mismedicated and correctly medicated) were retrospectively determined in patients enrolled into four similar clinical trials. T-test and chi-square/Fisher's exact were used wherever appropriate. Results: Of 566 patients (RCBDI n = 320, RCBDII n = 246), 46% had any lifetime AD, 67% had any lifetime SUD and 40% had any recent SUD. Overall, 12% of patients were unmedicated, 37% were mismedicated at the onset of first mania/hypomania and 51% were correctly medicated. Presence of lifetime ADs and recent SUDs was associated with fewer mood stabiliser treatments. Patients with RCBDI were more likely correctly medicated than those with RCBDII (OR = 3.64) regardless of the presence (OR = 2.6) or absence (OR = 4.2) of ADs, or the presence (OR = 2.8) or absence (OR = 3.13) of recent SUDs. Presence of lifetime ADs and recent SUDs increased the risk for mismedicated in RCBDI with odds ratios of 1.8 and 1.9, respectively, but not in RCBDII. Conclusion: In this multi-morbid cohort of patients with RCBD, 51% of patients (64% of RCBDI and 33% with RCDBII) were correctly medicated with a mood stabiliser after the onset of first mania/hypomania. The presence of ADs and SUDs was associated with an increased risk of mismedicated in patients with RCBDI, but not with RCBDII.

Ghodasara SL; Davidson MA; Reich MS; Savoie CV; Rodgers SM. Assessing student mental health at the Vanderbilt University School of Medicine. Academic Medicine 86(1): 116-121, 2011. (37 refs.)

Purpose: To determine the prevalence rates of four major categories of mental illness among medical students and to examine associations between these illnesses and a range of demographic variables. Method: The authors invited all 330 first-, second-, and third-year medical students at Vanderbilt University School of Medicine to participate in a survey during winter 2008-2009. Students completed an anonymous written questionnaire assessing the prevalence of depression, anxiety, eating disorders, and alcohol and drug use disorders. Additionally, the authors obtained student demographic information to investigate variations in rates of illness based on interindividual differences. Results: Most students (301; response rate: 91.2%) completed the survey. The authors found that depression and anxiety were more prevalent in the Vanderbilt medical student population than in their nonmedical peer group. The authors found that 37 (12%) of the students were borderline for possible alcohol abuse and 3 (1%) were problem drinkers, 1 (0.3%) had a possible drug abuse disorder, and 3 (1%) had possible eating disorders. Whereas exercising one to three times per week was associated with lower rates of both depression and anxiety, having a family history of mental illness was associated with higher eating disorder scores and anxiety. There was an association between gender and all disorders. Conclusions: Insight into the prevalence of mental health disorders in the medical student population and the variables that may influence them provides important information for medical schools as they develop more robust and effective wellness programs to help students in these very stressful learning environments.

Goodwin RD; Keyes KM; Stein MB; Talley NJ. Peptic ulcer and mental disorders among adults in the community: The role of nicotine and alcohol use disorders. Psychosomatic Medicine 71(4): 463-468, 2009. (53 refs.)

Objective: Previous studies have documented links between peptic ulcer disease (PUD) and mood and anxiety disorders among adults in the community. Several substance use disorders (e.g., nicotine and alcohol dependence) are highly comorbid with mood/anxiety disorders and have been also linked with PUD. No previous study has examined the potentially explanatory role of substance use disorders in the link between mood and anxiety disorders and PUD. The objective of the study is to examine relationships between a range of mental disorders and PUD among adults in the United States and to examine the potentially explanatory role of substance use disorders in these links. Methods: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of US adults 18 years of age and over (n = 43,098). Diagnostic and Statistical Manual for Mental Disorders IV diagnoses of mood, anxiety, and substance use disorders were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV, and PUD status was assessed via self-report. Results: Findings show that mood/anxiety disorders were associated with PUD. Specifically, generalized anxiety disorder (GAD) (Odds ratio (OR) = 3.43) was most strongly associated with PUD, followed by panic disorder (OR = 3.11), dysthymia (OR = 3.59), and bipolar disorder (OR = 2.91). The relationships between most mood/anxiety disorders and PUD were substantially attenuated after adjusting for nicotine and alcohol dependence. Conclusions: Mood/anxiety disorders are associated with increased rates of PUD; nicotine and alcohol dependence seems to play a substantial role in explaining the link with PUD.

Goodwin RD; Lipsitz JD; Keyes K; Galea S; Fyer AJ. Family history of alcohol use disorders among adults with panic disorder in the community. Journal of Psychiatric Research 45(8): 1123-1127, 2011. (44 refs.)

Objective: Clinical studies suggest a familial association between panic disorder and alcohol use disorders but this relationship has not been examined in a representative community sample. The objective of this study is to examine the familial association between panic disorder and alcohol use disorders among adults in the community. Method: Data were drawn from the NESARC, a nationally representative sample of over 43,000 adults in the United States. Rates of alcohol use disorders were examined using the family history method in first-degree relatives (FDRs) of adults with panic disorder. Analyses were adjusted for demographics, alcohol use disorders in the proband, and anxiety disorders in the FDRs. Results: First-degree relatives of adults with panic disorder have significantly higher odds of alcohol use disorders, compared with FDRs of adults without panic disorder. These associations persist after adjusting for demographic characteristics, alcohol use disorders in the proband, and anxiety disorders in the FDR's. Conclusions: Consistent with findings from clinical studies, this is the first population-based study to show a familial link between panic disorder and alcohol use disorders. This association appears independent of the influence of comorbidity of alcohol use disorders and anxiety disorders, suggesting a potential familial and/or genetic pathway. Future longitudinal studies will be needed to further understand the mechanism of this observed association.

Grover KW; Goodwin RD; Zvolensky MJ. Does current versus former smoking play a role in the relationship between anxiety and mood disorders and nicotine dependence? Addictive Behaviors 37(5): 682-685, 2012. (25 refs.)

Objective: Research suggests an association between nicotine dependence and anxiety/mood disorders. Yet, less is known about the role of current versus former smoking in the association between nicotine dependence and these psychiatric disorders. The purpose of the present study was to investigate the relations between anxiety/mood disorders and 1) nicotine dependence and 2) current versus former smoking. Method: Data were drawn from the 2001-2002 National Epidemiologic Survey of Alcohol and Related Conditions, a nationally representative sample of over 43.000 adults in the United States. Analyses examined whether dependent versus non-dependent smoking and current versus former smoking were associated with anxiety/mood disorders. Results: Current dependent, but not non-dependent, smoking was associated with significantly increased odds of anxiety/mood disorders. There was no association between anxiety/mood disorders and former dependent smoking, compared with never smoking. However, compared with never smoking, former non-dependent smoking was associated with significantly decreased odds of current anxiety/mood disorders. Conclusions: Current dependent smoking was positively associated with current anxiety/mood disorders, and former non-dependent smoking was negatively associated with current anxiety/mood disorders. The present research is important for understanding the relation between nicotine dependence and anxiety/mood disorders, and why it may be difficult for people with these disorders to quit smoking. The results from this study indicate that greater clinical attention could be directed toward the role of anxiety/mood disorders in smoking cessation.

Hall W; Degenhardt L; Teesson M. Understanding comorbidity between substance use, anxiety and affective disorders: Broadening the research base. Addictive Behaviors 34(6-7): 526-530, 2009. (67 refs.)

In this paper, we argue that the research base for understanding comorbidity between substance use and other mental disorders needs to be broadened. We specifically advocate for: 1) more prospective epidemiological studies of relationships between alcohol and other drug use disorders and anxiety and mood disorders; 2) greater use of twin study designs to disentangle shared genetic and environmental contributions to comorbidity; 3) prospective neuroimaging studies of the effects of early and sustained alcohol and drug use on the developing adolescent brain; 4) a greater focus on the effects on comorbidity of primary and secondary prevention interventions for substance use, anxiety, affective and conduct disorders among children and adolescents; and 5) better evaluations of the impact of treatment upon persons with comorbid substance use and other mental disorders.

Hall W; Degenhardt L; Teesson M. Understanding comorbidity between substance use, anxiety and affective disorders: Broadening the research base (Reprinted from Addictive Behaviors, vol 34, pg 526-530, 2009). Addictive Behaviors 34(10, Special Issue): 795-799, 2009. (68 refs.)

In this paper we argue that the research base for understanding comorbidity between substance use and other mental disorders needs to be broadened. We specifically advocate for: 1) more prospective epidemiological Studies of relationships between alcohol and other drug use disorders and anxiety and mood disorders: 2) greater use of twin study designs to disentangle shared genetic and environmental contributions to comorbidity; 3) prospective neuroimaging studies of the effects of early and Sustained alcohol and drug use on the developing adolescent brain; 4) a greater focus On the effects on comorbidity of primary and secondary prevention interventions for Substance use, anxiety, affective and conduct disorders among children and adolescents: and 5) better evaluations of the impact of treatment upon persons with comorbid substance use and other mental disorders.

Hassan I; Ali R. The association between somatic symptoms, anxiety disorders and substance use. A literature review. (review). Psychiatric Quarterly 82(4): 315-328, 2011. (27 refs.)

The aim of this article is to review the association between somatic symptoms, anxiety disorders and substance use. A Pub Med based literature review was conducted using various combinations of keywords related to substance use, somatic symptoms and anxiety. In various studies somatic symptoms were found to be associated with substance use. Anxiety disorders were found to have a high co-morbidity with substance use in most studies. However, several of the reviewed studies also included depressive symptoms which might have confounded the results. None of the studies was specifically aimed to find out if somatic symptoms in substance users represent an underlying primary anxiety disorder. Somatic symptoms and anxiety disorders are commonly noticed in substance users. Further studies are needed to clarify these associations since they may have significant clinical implications.

Hofmann SG; Richey JA; Kashdan TB; McKnight PE. Anxiety disorders moderate the association between externalizing problems and substance use disorders: Data from the National Comorbidity Survey-Revised. Journal of Anxiety Disorders 23(4): 529-534, 2009. (33 refs.)

Anxiety disorders and externalizing problems are both associated with substance use disorders. However, the nature of this relationship remains unclear. To examine whether presence of an anxiety disorder changes the association between externalizing problems (conduct disorder, oppositional defiant disorder, and attention deficit hyperactivity disorder) and substance use disorders, we analyzed data from the National Comorbidity Survey-Replication, which is based on a nationally representative sample of 9282 English-speaking adults. Presence of externalizing problems was associated with an increased odds for alcohol abuse (OR: 6.7, CI: 5.6-8.1), alcohol dependence (OR: 7.6, CI: 5.9-9.6), substance abuse (OR: 9.9. CI: 8.1-12.2), and substance dependence (OR: 13.1. CI: 9.6-17.8). Similarly, anxiety disorders were associated with increased odds for substance use disorders. The highest association was found between post-traumatic stress disorder and substance use disorder (OR: 9.2, CI: 5.4-15.5). Individuals who met diagnostic criteria for an anxiety disorder and externalizing problems showed consistently and significantly lower odds for substance use problems than subjects with externalizing problems without a comorbid anxiety disorder. The results suggest that presence of any anxiety disorder reduces the association between externalizing problems and substance use disorders, possibly because the fear of bodily symptoms prevents individuals with externalizing problems from engaging in drug-seeking behaviors.

Howland RH; Rush AJ; Wisniewski SR; Trivedi MH; Warden D; Fava M et al. Concurrent anxiety and substance use disorders among outpatients with major depression: Clinical features and effect on treatment outcome. Drug and Alcohol Dependence 99(1-3): 248-260, 2009. (72 refs.)

Background: Depressed patients often present with comorbid anxiety and/or substance use disorder. This report compares the four groups defined by the disorders (anxiety disorder, substance use disorder, both, and neither) in terms of baseline clinical and sociodemographic features, and in terms of outcomes following treatment with citalopram (a selective serotonin reuptake inhibitor). Methods: The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial enrolled 2838 outpatients with non-psychotic major depressive disorder (MDD) from 18 primary and 23 psychiatric care clinics. Clinical and sociodemographic features were assessed at baseline. These baseline features and the treatment outcomes following treatment with citalopram were compared among the four groups. Results: Participants with non-psychotic MDD and comorbid anxiety and/or Substance use disorder showed several distinctive baseline sociodemographic and clinical features. They also showed greater depression severity; length of illness; likelihood of anxious, atypical or melancholic features; more intolerance/attrition; and worse remission/response outcomes with treatment. Participants with either anxiety or substance use disorder showed Outcomes generally intermediate between those with both and those with neither. Conclusions: Comorbid anxiety and/or Substance use disorder are clinically identifiable, and their presence may define distinct MDD subgroups that have more problems and worse pharmacological treatment Outcomes. They may benefit from more aggressive, multi-faceted treatment and psychosocial rehabilitation targeted at reducing their psychological comorbidity and functional impairment.

Ilgen MA; Price AM; Burnett-Zeigler I; Perron B; Islam K; Bohnert ASB et al. Longitudinal predictors of addictions treatment utilization in treatment-naive adults with alcohol use disorders. Drug and Alcohol Dependence 113(2-3): 215-221, 2011. (43 refs.)

Background: Despite the substantial prevalence of alcohol use disorders (AUDs), prior research indicates that most people with AUDs never utilize either formal or informal treatment services. Several prior studies have examined the characteristics of individuals with AUDs who receive treatment; however, limited longitudinal data are available on the predictors of receiving AUD services in treatment-naive individuals with AUDs. Methods: This study utilized data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) to identify adults in Wave 1 who met criteria for an AUD within the last 12 months and reported no prior lifetime alcohol treatment (N = 2760). These individuals were surveyed again at Wave 2, approximately 3-4 years later (N = 2170). This study examined the Wave 1 demographic and psychiatric conditions that were associated with receipt of AUD treatment services between Waves 1 and 2. Results: In multivariable analyses, use of AUD treatment services between Waves 1 and 2 was significantly more likely among those who were male, non-Caucasian, younger, had lower income, and who had health insurance. Additionally, those who met criteria for a baseline drug use disorder, anxiety disorder or a personality disorder were more likely to receive AUD treatment. Conclusions: Treatment was more often utilized in those who had more severe baseline psychopathology and in those with fewer economic resources. These findings highlight the need to broaden the types of care available to individuals with AUDs to increase the appeal of AUD services.

Ip EJ; Barnett MJ; Tenerowicz MJ; Perry PJ. The Anabolic 500 Survey: Characteristics of male users versus nonusers of anabolic-androgenic steroids for strength training. Pharmacotherapy 31(8): 757-766, 2011. (34 refs.)

Study Objective. To contrast the characteristics of two groups of men who participated in strength-training exercise those who reported anabolic-androgenic steroid (AAS) use versus those who reported no AAS use. Design. Analysis of data from the Anabolic 500, a cross-sectional survey. Participants. Five hundred six male self-reported AAS users (mean age 29.3 yrs) and 771 male self-reported nonusers of AAS (mean age 25.2 yrs) who completed an online survey between February 19 and June 30, 2009. Measurements and Main Results. Respondents were recruited from Internet discussion boards of 38 fitness, bodybuilding, weightlifting, and steroid Web sites. The respondents provided online informed consent and completed the Anabolic 500, a 99-item Web-based survey. Data were collected on demographics, use of AAS and other performance-enhancing agents, alcohol and illicit drug use, substance dependence disorder, other Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnoses, and history of sexual and/or physical abuse. Most (70.4%) of the AAS users were recreational exercisers who reported using an average of 11.1 performance-enhancing agents in their routine. Compared with nonusers, the AAS users were more likely to meet criteria for substance dependence disorder (23.4% vs 11.2%, p<0.001), report a diagnosis of an anxiety disorder (10.1% vs 6.1%, p=0.010), use cocaine within the past 12 months (11.3% vs 4.7%, p<0.001), and report a history of sexual abuse (6.1% vs 2.7%, p=0.005). Conclusion. Most of the AAS users in this study were recreational exercisers who practiced polypharmacy. The AAS users were more likely than nonusers to meet criteria for substance dependence disorder, report a diagnosis of an anxiety disorder, report recent cocaine use, and have a history of sexual abuse. The information uncovered in this study may help clinicians and researchers develop appropriate intervention strategies for AAS abuse.

Kenna GA. Medications acting on the serotonergic system for the treatment of alcohol dependent patients. (review). Current Pharmaceutical Design 16(19, special issue): 2126-2135, 2010. (115 refs.)

Research suggests that alcoholics show comparatively lower levels of serotonin (5-HT) than non-alcoholics. Medications aimed at increasing synaptic 5-HT have long been studied as potential treatments for alcoholism. Studies with selective serotonin reuptake inhibitors (SSRI) in a heterogeneous population of non-depressed alcoholics have produced inconsistent results. Further exploration involved whether or not treatment of co-morbid alcoholism and depression was a more practical approach. However, even in the presence of co-occurring depression, antidepressants in general lack the power to demonstrate a significant reduction of alcohol use among alcohol dependent patients with carefully diagnosed major depression. Further statistical analysis has also determined that perhaps genotypic and phenotypic variations differ for persons with alcohol dependence including those with or without comorbid alcohol dependence and depression suggesting important subgroups might respond differently to treatments. Clinical trials have also used the anxiolytic buspirone, a 5-HT1A partial agonist, as many alcoholics suffer from anxiety. When controlling for baseline anxiety, buspirone was no more effective than placebo for alcoholic patients. Another serotonergic drug, ritanserin, did not demonstrate effectiveness in relapse prevention in alcohol dependence. However, research on the use of the 5-HT3 antagonist ondansetron for alcohol dependence continues to provide promising results, particularly for patients with early onset alcoholism. As demonstrated by the studies with serotonergics, responses based on individual variables suggest that alcoholics may respond differentially based on various serotonin 5-HT subtypes. Of course, future studies need to further delineate and confirm the differences between these alcoholic subtypes.

Kushner MG; Sletten S; Donahue C; Thuras P; Maurer E; Schneider A et al. Cognitive-behavioral therapy for panic disorder in patients being treated for alcohol dependence: Moderating effects of alcohol outcome expectancies. Addictive Behaviors 34(6-7): 554-560, 2009. (37 refs.)

Anxiety disorders commonly co-occur with alcohol use disorders and reliably mark a poor response to substance abuse treatment. However, treating a co-occurring anxiety disorder does not reliably improve substance abuse treatment outcomes. Failure to account for individual differences in the functional dynamic between anxiety symptoms and drinking behavior might impede the progress and clarity of this research program. For example, while both theory and research point to the moderating role of tension-reduction alcohol outcome expectancies (TR-AOEs) in the association between anxiety symptoms and alcohol use, relevant treatment studies have not typically modeled TR-AOE effects. We examined the impact: of a hybrid cognitive-behavioral therapy (H-CBT) treatment for panic disorder (independent variable) on response to a community-based alcohol dependence treatment program (dependent variable) in patients with higher vs. lower TR-AOEs (moderator). The H-CBT treatment was generally effective in relieving participants' panic symptoms relative to controls. However, TR-AOEs interacted with study cohort (H-CBT vs. control) in predicting response to substance abuse treatment. As expected, the H-CBT was most effective in improving alcohol use outcomes among those with the highest TR-AOEs. The study's primary methodological limitations are related to the quasi-experimental design employed.

Lawrence D; Considine J; Mitrou F; Zubrick SR. Anxiety disorders and cigarette smoking: Results from the Australian Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry 44(6): 520-527, 2010. (34 refs.)

Objective: The aim of this study was to describe current and daily smoking rates, and smoking cessation rates in adults with anxiety disorders, by type of disorder, severity, use of services, and time since first onset of symptoms. Method: Data were taken from the 2007 National Survey of Mental Health and Wellbeing, a nationally representative probability sample of 8841 Australian adults aged 16-85 years. The survey assessed symptoms of mental disorders including anxiety disorders using a fully structured interview, the Composite International Diagnostic Interview (CIDI) Version 3.0. Results: More than one-fifth of Australian adult smokers had 12-month anxiety disorders. Smoking rates increased with illness severity, but even in those with mild anxiety disorders the smoking rate was double that of adults with no lifetime history of mental disorders. In the majority of adults with anxiety disorders the first onset of symptoms was 10 or more years prior to the survey. Median duration of daily smoking was 22 years in adults with anxiety disorders (95% CI: 20-26 years) compared with 14 years for adults with no lifetime history of mental disorder (95% CI: 12-16 years). Adult smokers with anxiety disorders were significantly less likely to cease daily smoking (hazard ratio 0.57; 95% CI: 0.49-0.69). Conclusions: People with anxiety disorders are over-represented among smokers, are less likely to cease daily smoking and on average smoke for longer exposing them to greater risk of tobacco-related harm. The small proportion of adults with anxiety disorders who access services, and the small differences in smoking and smoking cessation rates between service users and non-users suggest that targeted population-based rather than service-based anti-smoking strategies are required to reach this vulnerable population group, who represent a signifi cant proportion of Australia's daily smokers.

Liang WB; Chikritzhs T. Affective disorders, anxiety disorders and the risk of alcohol dependence and misuse. British Journal of Psychiatry 199(3): 219-224, 2011. (24 refs.)

Background: It is unclear whether common affective disorders and anxiety disorders increase the risk of alcohol dependence and alcohol misuse. Aims: To investigate whether affective disorders and anxiety disorders increase the risk of alcohol dependence and alcohol misuse. Method This study is a retrospective cohort study based on data collected from the 2007 Australia Mental Health and Well-Being survey. Both Poisson and logistic regression models were used for multivariate analysis. Results: Participants with affective disorders (relative risk (RR)=5.46, 95% CI 4.08-7.31 for alcohol dependence within 5 years of onset; RR=2.77, 95% CI 1.93-3.99 after first 5 years) and anxiety disorders (RR=3.33, 95% CI 2.37-4.68 for alcohol dependence within first 5 years of onset; RR=3.56, 95% CI 2.72-4.64 after first 5 years) were at higher risk of alcohol misuse and alcohol dependence. Conclusions: Common affective disorders and anxiety disorders may increase the risk of alcohol dependence and alcohol misuse among the Australian population.

Martins SS; Gorelick DA. Conditional substance abuse and dependence by diagnosis of mood or anxiety disorder or schizophrenia in the US population. Drug and Alcohol Dependence 119(1-2): 28-36, 2011. (46 refs.)

Background: Little is known about the association of various psychiatric disorders with the risk of developing dependence or abuse among users of various psychoactive substances (conditional dependence, CD; conditional abuse, CA). Objectives: Evaluate the association of psychiatric disorders with CA only, CD only and CA + CD. Method: Secondary analysis of data from 43,093 non-institutionalized US adults in the first wave (2001-2002) of the National Epidemiological Survey on Alcohol and Related Conditions. A structured diagnostic interview allowed classification by lifetime psychiatric diagnosis (DSM-IV criteria) and psychoactive substance use. Data were analyzed using weighted proportions, 95% CIs, and weighted logistic regression models to generate odds ratios (OR) adjusted for socio-demographic characteristics. Results: Psychiatric disorders were associated with higher prevalence of psychoactive substance use, regardless of type of disorder or substance. CA, CD and CA + CD prevalence rates were generally higher than unconditional prevalence rates among respondents with and without psychiatric disorders. Respondents with multiple disorders (mainly mood and anxiety disorders) had higher rates of CA + CD on most, but not all, psychoactive substances (e.g.. not heroin), while schizophrenia was associated only with higher rates of tranquilizer CA + CD. Psychiatric disorders had few associations with CA only and CD only on psychoactive substances. Conclusion: Study findings suggest that mood and anxiety disorders are associated with increased prevalence of substance use and increased transition from use to CA and CD, while schizophrenia is associated with increased transition from abstinence to use, especially for marijuana. Findings did not support the self-medication hypothesis of substance use disorders.

Menary KR; Kushner MG; Maurer E; Thuras P. The prevalence and clinical implications of self-medication among individuals with anxiety disorders. Journal of Anxiety Disorders 25(3): 335-339, 2011. (21 refs.)

Alcohol dependence (AD) is more likely to occur among individuals with rather than without an anxiety disorder. Self-medication theory (SMT) holds that drinking behavior is negatively reinforced when alcohol temporarily reduces anxiety and that the resulting escalation of drinking increases the risk for AD. We set out to empirically scrutinize SMT using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) dataset. We found that only a minority (about 20%) of anxiety disordered individuals endorsed drinking to control anxiety symptoms. This minority drank more alcohol, had a higher cross-sectional rate of AD, and was at higher risk for developing new AD over four years compared to anxiety disordered non-self-medicators and individuals with no anxiety disorder. Consistent with SMT, increased prospective risk for AD among self-medicators is partially mediated by an increased level of alcohol use. Understanding the processes that promote and inhibit self-medication should be a priority for anxiety disorder researchers.

Morean ME; Corbin WR; Sinha R; O'Malley SS. Parental history of anxiety and alcohol-use disorders and alcohol expectancies as predictors of alcohol-related problems. Journal of Studies on Alcohol and Drugs 70(2): 227-236, 2009. (68 refs.)

Objective: Research has consistently identified a family history of alcoholism as a risk factor for alcohol-related problems, and global positive expectancies have been found to moderate this association. High rates of comorbidity between alcohol use and anxiety disorders suggest that a family history of anxiety disorders may also increase risk. Further, expectations of negative reinforcement (e.g., tension reduction) have been found to moderate the influence of anxiety-related traits. The current study sought to extend previous research by examining the influence of parental history of alcoholism, anxiety disorders, and the combination, as predictors of alcohol-related problems, Expectancies of global positive changes and tension reduction were hypothesized to moderate the influence of parental history of alcoholism and anxiety, respectively. Method: Direct interviews with parents assessed their history of alcoholism and anxiety for 144 offspring (ages 18-32; 53.5% male) creating four groups: those with a parental history of alcoholism (27.80%), anxiety (22.20%), both alcoholism and anxiety (33.30%), and no history of psychopathology (16.70%). Established measures assessed the offsprings' alcohol expectancies, alcohol use, and alcohol-related problems. Results: Although expected interactions between parental alcoholism and global positive expectancies and between parental anxiety and tension-reduction expectancies were not found, global positive expectancies were associated with alcohol-related problems among the group with parental history of both alcoholism and anxiety. Conclusions: The results suggest that the relation between parental history of alcoholism and global positive expectancies observed in previous studies may be strongest among individuals with a comorbid parental history of alcohol and anxiety disorders. Incorporating expectancies into interventions targeting individuals with a comorbid parental history of alcohol and anxiety disorders may have utility.

Piper ME; Cook JW; Schlam TR; Jorenby DE; Baker TB. Anxiety diagnoses in smokers seeking cessation treatment: Relations with tobacco dependence, withdrawal, outcome and response to treatment. Addiction 106(2): 418-427, 2011. (51 refs.)

Aims: To understand the relations among anxiety disorders and tobacco dependence, withdrawal symptoms, response to smoking cessation pharmacotherapy and ability to quit smoking. Design: Randomized placebo-controlled clinical trial. Participants received six 10-minute individual counseling sessions and either: placebo, bupropion SR, nicotine patch, nicotine lozenge, bupropion SR + nicotine lozenge or nicotine patch + nicotine lozenge. Setting: Two urban research sites. Participants: Data were collected from 1504 daily smokers (> 9 cigarettes per day) who were motivated to quit smoking and did not report current diagnoses of schizophrenia or psychosis or bupropion use. Measurements: Participants completed baseline assessments, the Composite International Diagnostic Interview and ecological momentary assessments for 2 weeks. Findings: A structured clinical interview identified participants who ever met criteria for a panic attack (n = 455), social anxiety (n = 199) or generalized anxiety disorder (n = 99), and those who qualified for no anxiety diagnosis (n = 891). Smokers with anxiety disorders reported higher levels of nicotine dependence and pre-quit withdrawal symptoms. Those ever meeting criteria for panic attacks or social anxiety disorder showed greater quit-day negative affect. Smokers ever meeting criteria for anxiety disorders were less likely to be abstinent at 8 weeks and 6 months post-quit and showed no benefit from single-agent or combination-agent pharmacotherapies. Conclusions: Anxiety diagnoses were common among treatment-seeking smokers and were related to increased motivation to smoke, elevated withdrawal, lack of response to pharmacotherapy and impaired ability to quit smoking. These findings could guide treatment assignment algorithms and treatment development for smokers with anxiety diagnoses.

Piper ME; Smith SS; Schlam TR; Fleming MF; Bittrich AA; Brown JL et al. Psychiatric disorders in smokers seeking treatment for tobacco dependence: Relations with tobacco dependence and cessation. Journal of Consulting and Clinical Psychology 78(1): 13-23, 2010. (72 refs.)

Objective: The present research examined the relation of psychiatric disorders to tobacco dependence and cessation outcomes. Method. Data were collected from 1,504 smokers (58.2% women; 83.9% White; mean age = 44.67 years, SD = 11.08) making an aided smoking cessation attempt as part of a clinical trial. Psychiatric diagnoses were determined with the Composite International Diagnostic Interview structured clinical interview. Tobacco dependence was assessed with the Fagerstrom Test of Nicotine Dependence (FTND) and the Wisconsin Inventory of Smoking Dependence Motives (WISDM). Results: Diagnostic groups included those who were never diagnosed, those who had ever been diagnosed (at any time, including in the past year), and those with past-year diagnoses (with or without prior diagnosis). Some diagnostic groups had lower follow-up abstinence rates than did the never diagnosed group (ps < .05). At 8 weeks after quitting, strong associations were found between cessation outcome and both past-year mood disorder and ever diagnosed anxiety disorder. At 6 months after quitting, those ever diagnosed with an anxiety disorder (OR = .72, p = .02) and those ever diagnosed with more than one psychiatric diagnosis (OR = .74, p = .03) had lower abstinence rates. The diagnostic categories did not differ in smoking heaviness or the FTND, but they did differ in dependence motives assessed with the WISDM. Conclusion: Information on recent or lifetime psychiatric disorders may help clinicians gauge relapse risk and may suggest dependence motives that are particularly relevant to affected patients. These findings also illustrate the importance of using multidimensional tobacco dependence assessments.

Robinson J; Sareen J; Cox BJ; Bolton JM. Role of self-medication in the development of comorbid anxiety and substance use disorders: A longitudinal investigation. Archives of General Psychiatry 68(8): 800-807, 2011. (52 refs.)

Context: Self-medication of anxiety symptoms with alcohol, other drugs, or both has been a plausible mechanism for the co-occurrence of anxiety disorders and substance use disorders. However, owing to the cross-sectional nature of previous studies, it has remained unknown whether self-medication of anxiety symptoms is a risk factor for the development of incident substance use disorder or is a correlate of substance use. Objective: To examine whether self-medication confers risk of comorbidity. Design: A longitudinal, nationally representative survey was conducted by the National Institute on Alcohol Abuse and Alcoholism. The National Epidemiologic Survey on Alcohol and Related Conditions assessed DSM-IV psychiatric disorders, self-medication, and sociodemographic variables at 2 time points. Setting: The United States. Participants: A total of 34 653 US adults completed both waves of the survey. Wave 1 was conducted in 2001-2002, and wave 2 interviews occurred 3 years later (2004-2005). Main Outcome Measures: Incident substance use disorders in participants with baseline anxiety disorders and incident anxiety disorders in those with baseline substance use disorders. Results: Logistic regression analyses revealed that self-medication conferred a heightened risk of new-onset substance use disorders in those with baseline anxiety disorders (adjusted odds ratios [AORs], 2.50-4.99 [P <.01]). Self-medication was associated with an increased risk of social phobia (AOR in baseline alcohol use disorders, 2.13 [P=.004]; AOR in baseline drug use disorders, 3.17 [P=.001]). Conclusions: Self-medication in anxiety disorders confers substantial risk of incident substance use disorders. Conversely, self-medication in substance use disorders is associated with incident social phobia. These results not only clarify several pathways that may lead to the development of comorbidity but also indicate at-risk populations and suggest potential points of intervention in the treatment of comorbidity.

Schneier FR; Foose TE; Hasin DS; Heimberg RG; Liu SM; Grant BF et al. Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine 40(6): 977-988, 2010. (59 refs.)

Background. To assess the prevalence and clinical impact of co-morbid social anxiety disorder (SAD) and alcohol use disorders (AUD, i.e. alcohol abuse and alcohol dependence) in a nationally representative sample of adults in the United States. Method. Data came from a large representative sample of the US population. Face-to-face interviews of 43093 adults residing in households were conducted during 2001-2002. Diagnoses of mood, anxiety, alcohol and drug use disorders and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV version. Results. Lifetime prevalence of co-morbid AUD and SAD in the general population was 2.4%. SAD was associated with significantly increased rates of alcohol dependence [odds ratio (OR) 2.8] and alcohol abuse (OR 1.2). Among respondents with alcohol dependence, SAD was associated with significantly more mood, anxiety, psychotic and personality disorders. Among respondents with SAD, alcohol dependence and abuse were most strongly associated with more substance use disorders, pathological gambling and antisocial personality disorders. SAD occurred before alcohol dependence in 79.7% of co-morbid cases, but co-morbidity status did not influence age of onset for either disorder. Co-morbid SAD was associated with increased severity of alcohol dependence and abuse. Respondents with co-morbid SAD and alcohol dependence or abuse reported low rates of treatment-seeking. Conclusions. Co-morbid lifetime AUD and SAD is a prevalent dual diagnosis, associated with substantial rates of additional co-morbidity, but remaining largely untreated. Future research should clarify the etiology of this comorbid presentation to better identify effective means of intervention.

Shafe S; Gilder DA; Montane-Jaime LK; Joseph R; Moore S; Crooks H et al. Co-morbidity of alcohol dependence and select affective and anxiety disorders among individuals of East Indian and African ancestry in Trinidad and Tobago. West Indian Medical Journal 58(2): 164-172, 2009. (63 refs.)

The present study sought to determine whether an association exists between alcohol dependence and select affective and anxiety disorders in patients presenting at substance abuse centres in Trinidad and Tobago(TT). The participants in this study were 143 alcohol dependents, of either East Indian ancestry (Indo-TT) or African ancestry (Afro-TT) and 109 controls matched by age, gender and ethnicity. A structured interview was used to gather information on demographics, psychiatric diagnoses and personal drinking and drug use. A blood sample was obtained and used to genotype for the presence of ADH and ALDH1 polymorphisms and serum levels of hepatic enzymes. Forty-one per cent of Indo-TT and 37% of Afro-TT with alcohol dependence had co-morbid major depressive disorders independent of alcohol and/or drug use. Thirty-nine percent of Indo-TT and 37% of Afro-TT with alcohol dependence had co-morbid major depression induced by alcohol or drug use. The severity of depression was significantly associated with severity of alcohol dependence. Neither major depression nor the severity of depressive episodes was associated with values of any liver function test or the presence of A-LDH1*2 or ADH1C*2 alleles. However in participants of African descent elevated alanine transaminase ALT was associated (p = 0.038) with not having substance-induced major depression. Co-morbidity of major depressive disorder with alcohol dependence is common in the two major ethnic groups in Trinidad and Tobago and appears to be as likely the consequence of drinking and/or drug use, as the cause. Clinicians should solicit a history of depression from patients with alcohol dependence.

Simon NM. Generalized anxiety disorder and psychiatric comorbidities such as depression, bipolar disorder, and substance abuse. Journal of Clinical Psychiatry 70(Supplement 2): 10-14, 2009. (30 refs.)

Generalized anxiety disorder (GAD) has a high rate of comorbidity with other psychiatric disorders, including major depressive disorder (MDD), bipolar disorder, other anxiety disorders, and substance use disorders. The similarities between GAD and MDD have led some to suggest that GAD should be reclassified as a mood disorder. The concurrence of GAD with another disorder heightens a patient's risk for impairment, disability, and suicidality. Clinical trials for GAD and disorders that are most likely to occur with GAD have generally not taken comorbidity into account, and there is a paucity of data guiding how comorbidity should inform treatment selection. Research into the biology and psychopathology underlying the high rate of comorbidity of GAD and into efficacious interventions for GAD with comorbidity is needed.

Torrens M; Gilchrist G; Domingo-Salyany A. Psychiatric comorbidity in illicit drug users: Substance-induced versus independent disorders. Drug and Alcohol Dependence 113(2-3): 147-156, 2011. (43 refs.)

Background: Few studies have differentiated between independent and substance-induced psychiatric disorders. In this study we determine the risks associated with independent and substance-induced psychiatric disorders among a sample of 629 illicit drug users recruited from treatment and out of treatment settings. Methods: Secondary analysis of five cross-sectional studies conducted during 2000-2006. Independent and substance-induced DSM-IV psychiatric diagnoses were assessed using the Psychiatric Research Interview for Substance and Mental Disorders, Results: Lifetime prevalence of Axis I disorders other than substance use disorder (SUD) was 41.8%, with independent major depression being the most prevalent (17%). Lifetime prevalence of antisocial or borderline personality disorders was 22.9%. In multinominal logistic regression analysis (SUD only as the reference group), being female (OR 2.45; 95% CI 1.59, 3.77) and having lifetime borderline personality disorder (OR 2.45; 95% CI 1.31, 4.59) remained significant variables in the group with independent disorders. In the group with substance-induced disorders, being recruited from an out of treatment setting (OR 3.50; 95% CI 1.54, 7.97), being female (OR 2.38; 95% CI 1.24, 4.59) and the number of SUD (OR 1.31; 95% CI 1.10, 1.57) remained significant in the model. These variables were also significant in the group with both substance-induced and independent disorders, together with borderline personality disorder (OR 2.53; 95% CI 1.03, 6.27). Conclusions: Illicit drug users show high prevalence of co-occurrence of mainly independent mood and anxiety psychiatric disorders. Being female, recruited from an out of treatment setting and the number of SUD, are risk factors for substance-induced disorders.

Van Dorn RA; Williams JH; Del-Colle M; Hawkins JD. Substance use, mental illness and violence: The co-occurrence of problem behaviors among young adults. Journal of Behavioral Health Services & Research 36(4): 465-477, 2009. (56 refs.)

A paucity of research exists in which the co-occurrence of substance use, mental illness, and violence in young adults is examined. Concurrently, there is also a lack of research explicating the contribution of theoretically based risk factors for these problematic outcomes in this population. This lack of both outcome and explanatory research equally affects the utility of theories and interventions for this population. This article utilizes a sample of N = 633 21-year-olds to examine the prevalence of (1) violence and substance use, (2) mental illness (i.e., mood and anxiety disorders) and substance use, and (3) the use of multiple substances and investigates the relationship between various social determinants and said outcomes. Overall, the prevalence rates for the comorbid conditions were low; although on average males had higher rates than did females. Individual attitudes, perceived opportunities, and recent stressful life events were associated with the co-occurrence of outcomes. Implications for behavioral health are explored.

Vincenti A; Ventriglio A; Baldessarini RJ; Talamo A; Fitzmaurice G; Centorrino F. Characteristics and clinical changes during hospitalization in bipolar and psychotic disorder patients with versus without substance-use disorders. Pharmacopsychiatry 43(6): 225-232, 2010. (40 refs.)

Background: Co-morbid substance-use disorders (SUDs) are prevalent among patients with severe psychiatric disorders, but the characteristics of such patients remain incompletely defined, and their current treatments and responses, poorly documented. Methods: We evaluated the records of 481 consecutive inpatients diagnosed with DSM-IV bipolar or schizoaffective disorders, or schizophrenia, admitted to McLean Hospital in 2004 or 2009. Demographic and clinical characteristics, and treatments, were extracted from hospital and pharmacy records for bivariate and multivariate analyses. Results: SUD prevalence increased 1.84-times from 2004 (31.3%) to 2009 (57.6%). Patients with (n = 204) versus without co-morbid SUDs (n = 277) were similar in many respects, but in multivariate modeling, the following factors were more likely with SUD, in rank-order: co-morbid anxiety disorders > men more than women > greater prevalence in 2009 vs. 2004 > younger age > greater doses of mood-stabilizers > shorter hospitalization. Conclusions: Hospitalized patients with severe primary psychiatric disorders, and comorbid SUD were more likely to be young and have anxiety disorders, to receive more combinations and higher doses of mood-stabilizers, and show more improvement in impulsivity and hostility, but otherwise differed little in treatment-responses. Prevalence of SUD rose substantially in the past five years, with increased but largely unproved use of mood-stabilizers.

Weinberger AH; Desai RA; Mckee SA. Nicotine withdrawal in US smokers with current mood, anxiety, alcohol use, and substance use disorders. Drug and Alcohol Dependence 108(1-2): 7-12, 2010. (35 refs.)

Background: The current study examined tobacco withdrawal symptoms and withdrawal-related discomfort and relapse in smokers with and without current mood disorders, anxiety disorders, alcohol use disorders (AUD), and substance use disorders (SUD). Methods: The subsample of current daily smokers (n = 8213) from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, Wave 1,2001-2002, full sample n = 43,093) were included in these analyses. Cross-sectional data compared smokers with and without current psychiatric disorders on withdrawal symptoms using logistic regression models. The effects of having a co-morbid psychiatric disorder and AUD/SUD compared to a psychiatric disorder alone on nicotine withdrawal were also examined. Results: Participants with a current mood disorder, anxiety disorder, AUD, or SUD were more likely to report withdrawal symptoms and reported more withdrawal symptoms than those without current disorders. Having a current mood disorder, anxiety disorder, or SUD was also associated with increased likelihood of withdrawal-related discomfort and relapse. There were no significant interactions between psychiatric disorders and AUDs/SUDs on withdrawal symptoms or behavior. Conclusions: Participants with a current Axis I disorder were more likely to experience tobacco withdrawal symptoms and withdrawal-related discomfort and relapse. Having a co-morbid psychiatric disorder and AUD/SUD did not synergistically increase the experience of withdrawal-related symptoms or relapse. It is important to identify Axis I disorders in smokers and provide these smokers with more intensive and/or longer treatments to help them cope with withdrawal symptoms and prevent relapse.

Wolitzky-Taylor K; Operskalski JT; Ries R; Craske MG; Roy-Byrne P. Understanding and treating comorbid anxiety disorders in substance users review and future directions. (review). Journal of Addiction Medicine 5(4): 233-247, 2011. (95 refs.)

Anxiety disorders commonly occur among those with substance use disorders. This article reviews the literature describing the prevalence and patterns of this comorbidity in epidemiological and clinical samples and theoretical models explaining this comorbidity, and reviews the effects of anxiety disorders on substance use outcomes and data from clinical trials that target comorbid anxiety disorders to examine the effects of treating anxiety disorders on substance use outcomes. Next, this review outlines evidence-based pharmacological and psychological treatments for anxiety disorders and provides treatment recommendations for those treating this comorbid population. Finally, a discussion of treatment-delivery issues is presented to address the important issues that arise when treating anxiety disorders in typical addictions-treatment settings.