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Association of Lifetime Mental Disorders and Subsequent Alcohol and Illicit Drug Use: Results From the National Comorbidity Survey–Adolescent Supplement
Accepted Manuscript Association of Lifetime Mental Disorders and Subsequent Alcohol and Illicit Drug use: Results from the National Comorbidity Survey–Adolescent Supplement Kevin P. Conway, PhD, Joel Swendsen, PhD, Mathilde M. Husky, PhD, Jian-Ping He, MS, Kathleen R. Merikangas, PhD PII:
S0890-8567(16)00070-8
DOI:
10.1016/j.jaac.2016.01.006
Reference:
JAAC 1367
To appear in:
Journal of the American Academy of Child & Adolescent Psychiatry
Received Date: 11 September 2015 Revised Date:
4 January 2016
Accepted Date: 10 January 2016
Please cite this article as: Conway KP, Swendsen J, Husky MM, He J-P, Merikangas KR, Association of Lifetime Mental Disorders and Subsequent Alcohol and Illicit Drug use: Results from the National Comorbidity Survey–Adolescent Supplement, Journal of the American Academy of Child & Adolescent Psychiatry (2016), doi: 10.1016/j.jaac.2016.01.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Association of Lifetime Mental Disorders and Subsequent Alcohol and Illicit Drug Use: Results From the National Comorbidity Survey-Adolescent Supplement RH: Substance Use and Comorbidity Kevin P. Conway, PhD; Joel Swendsen, PhD; Mathilde M. Husky, PhD; Jian-Ping He, MS; Kathleen R. Merikangas, PhD This article is discussed in an editorial by Dr. Karen Abram on page xx.
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Accepted January 28, 2016
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Dr. Conway is with the Division of Epidemiology, Services and Prevention Research at the National Institute on Drug Abuse (NIDA), Rockville, MD. Dr. Swendsen is with the École Pratique des Hautes Études (EPHE), Paris, the National Center for Scientific Research (CNRS), Paris, and University of Bordeaux, France. Dr. Husky is with the University of Paris Descartes, Paris. Dr. Merikangas and Ms. He are with the Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health (NIMH), Bethesda, MD.
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This work was supported by the Intramural Research Program of the National Institute of Mental Health (Z01MH002808-08). The National Comorbidity Survey Adolescent Supplement (NCS-A) and the larger program of related NCS surveys are supported by the National Institute of Mental Health (U01-MH60220). The views and opinions expressed in this article are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or US government. Ms. He served as the statistical expert for this research.
Disclosure: Drs. Conway, Swendsen, Husky, Merikangas, and Ms. He report no biomedical financial interests or potential conflicts of interest.
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Correspondence to Kathleen Ries Merikangas, PhD, Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health, 35 Convent Drive, MSC #3720 Bethesda, MD 20892; email: [email protected].
ACCEPTED MANUSCRIPT ABSTRACT Objective: To estimate the association of prior lifetime mental disorders with transitions across stages of substance use in a cross-sectional, nationally representative sample of US adolescents.
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Method: The sample includes 10,123 adolescents aged 13-18 who participated in the
National Comorbidity Survey–Adolescent Supplement (NCS-A), and who were directly
interviewed with the Composite International Diagnostic Interview (CIDI) Version 3.0 that
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generates criteria for DSM-IV disorders.
Results: Adolescents with prior lifetime mental disorders had high rates of both alcohol
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(10.3%) and illicit drug (14.9%) abuse with or without dependence. Alcohol and drug abuse were highest among adolescents with prior anxiety disorders (17.3% and 20%, respectively) and behavior disorders (15.6% and 24%, respectively). Any prior disorder significantly increased the risk of transition from non-use to first use, and from use to problematic use of
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either alcohol or illicit drugs. Multivariate models attenuated the magnitude of the risk of transition associated with each disorder, though prior weekly smoking and illicit drug use demonstrated significant risks of transitions across the three stages of alcohol or drug use, as
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did behavior disorders.
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Conclusion: The findings provide the first evidence from a nationally representative sample that prior mental disorders represent risk factors for the transition from non-use to use, and the progression to drug- and alcohol-related problems. Treatment of primary mental disorders is likely to be an important target for the prevention of secondary substance use disorders in youth. Key words: adolescence, alcohol use, comorbidity, drug use, epidemiology INTRODUCTION
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ACCEPTED MANUSCRIPT Nationally representative surveys of substance use disorders (SUDs) in adults1-3 have generated lifetime rates of SUDs that are only moderately higher than those among adolescents.4-8 This suggests that the majority of lifetime cases of SUDs have their onset in mid to late adolescence. However, while over three decades of research in psychiatric
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epidemiology have shown that the prevalence of these conditions varies considerably by sociodemographic characteristics and co-occurring mental disorders, few nationally
representative samples of American adolescents have systematically investigated the impact
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of prior mental disorders on multiple stages of substance use.1,7-12
The numerous of studies of adults consistently suggest that a history of mental
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disorders is a salient risk factor for diverse forms of SUDs.13-19 Although “forward telescoping” and other memory biases may reduce the reliability of such estimates,20 the tenyear follow-up of the National Comorbidity Survey, as well as the two-wave analyses of the National Epidemiologic Survey on Alcohol and Related Conditions, has confirmed the
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prospective risk posed by primary mental disorders.21-25 The etiologic importance of these associations is particularly relevant to youth in light of findings that most mental disorders, including the major categories of mood, anxiety, behavior, and eating disorders, each have an
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average earlier age of onset than SUDs.26
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Among the important advances in understanding the etiology of the substance use disorders among adults is the finding that risk factors may differ substantially by stage of substance use. In particular, the associations between common sociodemographic factors (such as sex or race) with both alcohol and illicit drug dependence have been shown to vary according to specific stages of use.2,3,27-29 The associations observed for prior mental disorders in adults have also been shown to vary according to stage of substance use, as well as by mental disorder type. 22 Research that clarifies the role and timing of prior mental
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ACCEPTED MANUSCRIPT disorders across substance use stages therefore holds promise for optimizing interventions designed to prevent substance use disorders. The existing regional or community studies have shown that the majority of youth with alcohol or drug use disorders have comorbid conduct disorder, oppositional defiant
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disorder, or depression30, and also that prior psychiatric conditions during adolescence predict substance use disorders later in life31-35 with some evidence of differential effects as a
function of gender and age.36 While nationally representative surveys conducted in the United
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States have also provided rich information concerning risk factors for substance use in
adolescents, notably including the National Survey on Drug Use and Health4,7,9, the National
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Health and Nutrition Examination Survey5, and the Monitoring the Future project6,8, the association of mental disorders with the risk of transition across the different stages of substance use has been conducted almost exclusively with adult samples. To address these concerns, the current study examines this topic in the National Comorbidity Survey –
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Adolescent Supplement (NCS-A), a nationally representative survey of youth aged 13 to 18 years conducted between February 2001 and January 2004. Using direct diagnostic interviews, information was collected for a large number of mental disorders as well as for
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diverse stages of alcohol and drug use, ranging from first opportunity to use substances, to
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abuse, and abuse with dependence. The objectives of the present investigation are to: (1) estimate the association among prior mental disorders among adolescents with the different stages of alcohol and illicit drug use; and (2) estimate the association between prior mental disorders and the probability of transition from earlier to later stages of use. METHOD Sample and Procedure The NCS-A is a cross-sectional, nationally representative face-to-face survey of 10,123 adolescents aged 13-18 years in the continental US.37 The survey was administered
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ACCEPTED MANUSCRIPT by trained lay interviewers from the Institute for Social Research at the University of Michigan. The NCS-A was carried out in a dual-frame sample that included a household subsample and a school subsample. 38-40 The overall NCS-A adolescent response rate combining the two subsamples was 82.9%. The recruitment and consent procedures were
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approved by the human subjects committees of both Harvard Medical School and the University of Michigan.
Comparisons of sample and population distributions on census sociodemographic
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variables, and in the school sample on school characteristics, documented only minor
differences that were corrected with post-stratification weighting. Once the survey was
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completed, cases were weighted for variation in within-household probability of selection (in the household subsample) and for residual discrepancies between the sample and the US population on the basis of sociodemographic and geographic variables. These weighting procedures are discussed in more detail elsewhere.38,39
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Sociodemographic variables examined in this report include age (in years), sex, and race/ethnicity. About half the sample was male (51.3%), and the mean age was 15.2 years, with a larger proportion of youth aged 13-14 years (36.2%), and approximately equal
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distributions of youth aged 15, 16, and 17-18 years. The sample was comprised of 65.6%
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non-Hispanic whites, 15.1% non-Hispanic blacks, and 14.4% Hispanics. Measures
Diagnostic assessment. Details of the diagnostic and risk factor measures are described
by Merikangas et al. 37 Briefly, adolescents were administered a modified version of the World Health Organization (WHO) Composite International Diagnostic Interview Version 3.0 (CIDI), a fully structured interview administered by trained lay interviewers to generate DSM-IV diagnoses.41 For the purpose of this investigation, age of onset of a lifetime mental disorder was defined as the age at which the individual met full diagnostic criteria for that disorder,
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ACCEPTED MANUSCRIPT grouped into five main categories including mood disorders (major depression or dysthymia, bipolar I or II disorder), phobia disorders (agoraphobia, social phobia, specific phobia, and separation anxiety disorder), anxiety disorders (generalized anxiety disorder, panic disorder, posttraumatic stress disorder [PTSD]), behavior disorders (attention-deficit/hyperactivity
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disorder [ADHD], conduct disorder, oppositional defiant disorder), and eating disorders
(anorexia, bulimia, binge eating disorder). Lifetime substance use disorders included alcohol and drug abuse, and individuals fulfilling abuse criteria were administered questions
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concerning dependence. In this way, instances of alcohol and drug dependence without a
history of abuse were not assessed. This report therefore presents both categories of abuse (with
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or without dependence). In addition to DSM-IV diagnoses, all respondents were asked about their use of diverse substances and the age at which specific stages of use first occurred. Adolescent self-reports of substance use have been found to have good concordance with parental reports.42 For alcohol, the lifetime use question concerned age at which respondents
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first (if ever) had a drink with alcohol, specified as beer, wine, wine coolers, and hard liquor (such as vodka, gin, whiskey, and mixed drinks). First regular use of alcohol was defined as the age at which the respondent first had at least 12 drinks within a single year as a proxy for non-
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experimental alcohol use that approximated monthly use. For illicit drugs, participants were
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asked the age at which they had first (if ever) consumed a range of specific substances, including marijuana or hashish; cocaine in any form (e.g. powder, crack, free base, coca leaves, or paste); tranquilizers, stimulants, pain killers, or other prescription drugs either without the recommendation of a health professional, or for any reason other than a health professional said they should be used; heroin, opium, glue, LSD, peyote, or any other drug. Participants were also asked about the first time they had an opportunity to drink alcohol or to use drugs, regardless of whether or not they used them. Opportunity to use was defined as when someone either offered them alcohol or drugs, or when the individual was present when others were
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ACCEPTED MANUSCRIPT using and could have used if he or she wanted to. The age of first opportunity to use substances was recorded separately for alcohol and drugs. In light of the very high availability of legal substances such as alcohol, only opportunity to use illicit drugs is examined in this investigation.
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Statistical Analysis
Cross-tabulations were used to calculate the prevalence of lifetime mental disorders having an onset at least one year prior to the onset of the different stages of alcohol and drug
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use. Conditional prevalence estimates for each alcohol or drug use stage were also calculated among those who had reached the earlier stage of use. Estimated projections of the
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cumulative probability of stages of alcohol or drug use as of age 18 were obtained by the actuarial method implemented in PROC LIFETEST in SAS (Version 9.2, SAS Institute). Predictors of transitions across the alcohol or drug stages were examined using discrete-time survival analysis using the logit function with person-year as the unit of analysis43. The
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person-year data array used in the transition from no use to first use of alcohol (or opportunity to use illicit drug) includes all years in the life of the respondents prior to and including their age at having their first alcoholic drink (or having opportunity to use illicit
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drug). The person-year data array for the following two stages of analysis (ever use to
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regular use, regular use to abuse/dependence for alcohol stages; having opportunity to use to any use, any use to abuse/dependent for illicit drug use stages) include all years beginning with the year after the earlier transition and continuing through the year of onset of the next transition or, for respondents who never made the next transition, through their age at interview. The associations of prior mental disorders with the stages of alcohol or drug use were examined in the survival model I series controlling for age, sex, and race/ethnicity. These associations were further examined when additionally adjusting for mental disorders in survival model II series. As the NCS-A data are both clustered and weighted, the Taylor
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ACCEPTED MANUSCRIPT series linearization method 44 implemented in SUDAAN (version 10, Research Triangle Institute) was used to estimate standard errors of logistic regression coefficients. The coefficients and standard errors were exponentiated to produce odds ratios (ORs) and 95% CIs. Significance of predictor sets was evaluated using Wald Chi-Square tests based on
consistently evaluated using .05-level two-sided tests. RESULTS
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design-adjusted coefficient variance-covariance matrices. Statistical significance was
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Prevalence of Alcohol and Drug Use Stages Among Adolescents With Prior Mental Disorders
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A total of 37.7% of adolescents experienced at least one mental disorder before the first use of alcohol, 47.6% before regular alcohol use, 66.6% before alcohol abuse with or without dependence. The percentage of adolescents for whom the prior disorder persisted into the year of onset for each of these stages was respectively 11.3%, 9.4%, and 7.8%. For drug
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use categories, 41.2% of adolescents met criteria for at least one mental disorder before having the opportunity to use drugs, 53.8% before first drug use, and 66.8% before drug abuse with or without dependence. The persistence of prior disorders into the same year of
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onset for these categories was respectively 9.5%, 10.5%, and 9.1%.
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By age 18, the majority of adolescents with pre-existing mental disorders had consumed alcohol at least once and had reported having the opportunity to use drugs. Furthermore, by this age, approximately one-third of all adolescents with mental disorders had become regular drinkers of alcohol or had used illicit drugs (Table 1). Adolescents with mental disorders also had high rates of both alcohol abuse with or without dependence (10.3%) and illicit drug abuse with or without dependence (14.9%). Regarding specific mental disorders, higher rates across the stages of alcohol and illicit drug use were typically observed for adolescents with anxiety or behavior disorders, whereas the lowest rates were
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ACCEPTED MANUSCRIPT observed for individuals with phobia or eating disorders. In particular, the rates for alcohol abuse with or without dependence were much higher among adolescents with prior anxiety disorders (17.3%) and behavior disorders (15.6%) than their counterparts with prior phobia disorders (8.5%) or eating disorders (9.7%). Nearly a quarter (24%) of adolescents with a
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prior behavior disorder and 20% of adolescents with an anxiety disorder developed illicit drug abuse with or without dependence, compared to 12% of adolescents with phobia
disorders. Notably, prior use of other substances was strongly associated with the stages of
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alcohol and drug use. Adolescents who already reached weekly smoking levels or who had previously used illicit drugs reported the highest rates of alcohol use, regular use, and abuse
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with or without dependence. In turn, those who had reached weekly smoking levels or regularly used alcohol had the highest rates of illicit drug use opportunity, drug use, and drug abuse with or without dependence.
Prior Mental Disorder as Predictor of Transition Across Alcohol Use Stages
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The association between prior mental disorders and the transitions from one stage of alcohol use to another was examined first for any class of mental disorder, adjusting for age, sex, and race/ethnicity (Table 2, Model I). Results show that having any prior mental disorder
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significantly increased the risk across the three transitions: from non-use to use of alcohol
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(OR=1.38), from use to regular alcohol use (OR=1.34), and from regular use to alcohol abuse with or without dependence (OR=1.84). Concerning the risk associated with specific mental disorders, we observed increased risk of transition to all three stages of alcohol use as a function with prior major depression/dysthymia (ORs= 1.51, 2.04, 1.88), specific phobia (ORs= 1.30, 1.67, 2.55), PTSD (ORs= 2.04, 1.46, 3.56), conduct disorder (ORs= 2.50, 2.36, 2.91), oppositional defiant disorder (ORs= 1.98, 2.00, 2.58), and eating disorders (ORs= 1.81,1.96, 1.81). With the exception of generalized anxiety disorder, all other specific disorders demonstrated a significantly higher risk of transition to at least one stage. Prior
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ACCEPTED MANUSCRIPT substance use was a robust risk factor for each stage of alcohol use, as both prior weekly smoking (ORs =6.65, 5.55, 4.51) and illicit drug use (ORs= 7.68, 6.75, 8.07) were associated with increased risk at each stage of alcohol use, respectively. In light of the substantial lifetime comorbidity observed for individuals with prior
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mental disorders, multivariate analyses were also performed with adjustments for all
comorbid disorders (Table 2, Model II). In these models, only prior weekly smoking and illicit drug use demonstrated significant risks of transitions across the three stages of alcohol
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use (ORs =3.08, 2.36, 1.89 for weekly smoking, respectively; and ORs=5.41, 4.70, 5.39 for illicit drug use, respectively) and most of the associations for classes or specific disorders
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were attenuated and non-significant. The risk posed by behavior disorders was most evident for initial transition to alcohol use (with the exception of ADHD, which was unrelated to any stage), although any behavioral disorder was also associated with the transition to abuse with or without dependence. In contrast to behavior disorders, mood disorders were more salient
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in later stages. More disparate effects were observed for phobia and anxiety disorders, with agoraphobia having a greater impact on earlier transitions, specific phobia on the transition to
stages.
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abuse with or without dependence, and with PTSD influencing transitions to the first and last
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Prior Mental Disorder as Predictor of Transition Across Drug Use Stages The associations between prior mental disorders and the transitions across drug use
stages were highly similar to those observed for alcohol stages (Table 3, Model I). The aggregate category of any prior mental disorder was significantly associated with the probability of transition across each stage of drug use and with increasing magnitude of risk across each subsequent stage. Similarly, for specific mental disorders, we found that having a prior mental disorder posed increased risk across all three stages for major depression/dysthymia (ORs= 1.95, 1.71, 1.79), social phobia (ORs= 1.44, 1.65, 2.08), panic
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ACCEPTED MANUSCRIPT disorder (ORs= 1.80, 1.83, 1.83), PTSD (ORs= 2.54, 1.91, 2.11), conduct disorder (ORs= 3.46, 4.29, 3.90), and oppositional defiant disorder (ORs= 1.92, 2.98, 2.04). Prior substance use was similarly a strong risk factor for each stage of drug use for both weekly smoking (ORs=9.06, 7.54, 4.18) and regular alcohol use (ORs=4.82, 4.01, 3.73). In contrast to
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findings for alcohol stages, however, the magnitude of risk associated with phobia disorders was generally greater in transitions to earlier than in later stages of drug use. Concerning multivariate analyses adjusting for other mental disorders (Table 3, Model II), prior substance
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use was robustly associated with the greatest risk of all transitions across drug use stages (ORs =6.64, 5.46, 2.83 for prior weekly smokers; ORs=3.69, 2.97, 2.67 for prior regular
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alcohol users). While attenuation was again observed for most classes of disorder, the magnitude of risk for transitions across the three stages remained highly significant for conduct disorder and oppositional defiant disorder. ADHD was significantly associated with the risk of having opportunities to use drugs (OR = 1.14) and drug use (OR = 1.65), but not
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drug abuse with or without dependence.
DISCUSSION
Despite converging evidence that most lifetime cases of substance use disorders are
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likely to begin in adolescence1,5,7,45 and that prior mental disorders constitute a major risk
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factor for these conditions,22-25,30-35 the majority of information for these forms of lifetime comorbidity in nationally representative samples has been acquired from adult respondents. Moreover, information on patterns of substance use in representative samples of adolescents has generally been limited to examining risk factors for specific stages of use, rather than examining predictors of transitions from one stage of use to another. The present investigation used data from the NCS-A to examine the association of a comprehensive range of mental and substance use disorders across the full adolescent age span in a nationally representative sample. The findings confirm that the burden of substance use disorders in
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ACCEPTED MANUSCRIPT adolescence is disproportionately concentrated among youth with prior mental disorders, and that this burden is not limited to treated samples. The risk posed by prior mental disorders also varied considerably by stages of substance use. Previous analyses of this sample indicated a prevalence estimate of 6.5% for alcohol
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abuse (with or without dependence) and 8.9% for drug abuse.1 The present study documents higher estimates of these same disorders (10.3% and 14.9%, respectively) among youth with prior mental disorders. This increase in risk was particularly strong for non-phobic anxiety
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disorders and behavior disorders for which the estimates were often three-fold higher than adolescent population estimates. In particular, alcohol and drug abuse was observed in 17.3%
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and 20%, respectively, of youth with prior anxiety disorders, and in 15.6% and 24% of youth with behavior disorders. The greatest overall risk for substance use disorders was associated with having progressed to more advanced stages of use of other substances (illicit drug use, and regular alcohol or tobacco use). While the reasons underlying the differential magnitude
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of association observed for specific prior disorders cannot be confirmed by the present methods, it is possible that they reflect diverse mechanisms of association. For example, alcohol has been shown to be used as a means of assuaging symptoms of anxiety disorders24
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and therefore its pharmacologic effects may explain why alcohol abuse was highest among
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adolescents with anxiety disorders than for any other comorbid condition. By contrast, the high concentration of illicit drug abuse among respondents with behavior disorders may reflect social or personality factors, such as the perceived deviance of the substance used, rather than a match between its pharmacologic effects and the psychiatric symptoms experienced by the individual.46. Although there has been substantial research identifying risk factors for aggregate substance use disorders, there is increasing evidence for differential risk for different stages of use. For example, investigations of adult samples have found that the association of both
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ACCEPTED MANUSCRIPT sociodemographic risk factors and prior mental disorders is often concentrated at very specific stages of the substance use trajectory, and that the nature of risk may even reverse for other stages.2,3,22,27-29 In the present study, the presence of any prior mental disorder was associated with greater probability of transition to initial use, to regular use, and to abuse with
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or without dependence. Bivariate models indicated that most individual disorders were associated with the risk for transition across several of these stages. However, the
multivariate models that account for lifetime comorbidity among the mental disorders
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demonstrated that the behavior disorders were associated with a stronger risk of initial
alcohol use, whereas mood or anxiety disorders had a stronger risk in transitions to regular
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use or to abuse with or without dependence. These patterns were different for drug use stages, where mood disorders (notably depression) and anxiety or phobic disorders had stronger associations on the risk of initial opportunity to use drugs, whereas behavior disorders had a generally significant and constant association across all stages of drug use. The lack of an
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independent association between ADHD and substance use concurs with other studies demonstrating the important mediating role of other comorbid behavior disorders.47 Whether for alcohol or for illicit drugs, both the unconditional and conditional models demonstrated
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comprehensively greater risk for transition to each stage if the adolescent had already attained
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more advanced stages of use of another substance. It is also important to note that the association of mental disorders with a given stage of substance use may reflect social processes (e.g., self-selection into peer groups) involving individual behavior or characteristics (e.g., depression),48 as well as broader factors that may affect parental monitoring due to the concentration of mental disorders within families.16 The strengths of this study include its use of comprehensive in-person diagnostic interviews that permit the assessment of a wide range of mental disorders and their association with different stages of substance use. Its application in a nationally
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ACCEPTED MANUSCRIPT representative sample spanning the entire adolescent age range also complements data acquired from other surveys of US youth concerning the role of mental disorders30 and extends findings from adults in the parallel NCS replication (NCS-R) study2,3 to earlier stages of development. Its limitations include the cross-sectional nature of the data and reliance of
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retrospective dating of disorder onset. While the assessment of such events in youth for
conditions that had occurred typically within a limited number of years should be less prone to bias than retrospective assessments in adults that may span several decades, forward
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telescoping and other memory biases cannot be excluded. In addition, this investigation
provided assessments of alcohol or illicit drug dependence only among youth meeting criteria
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for abuse, thereby ignoring individuals who experienced substance dependence alone. While this gated approach has been shown to have little impact on the magnitude or patterns of risk factors for substance use disorders,49 it likely reduces estimates for the overall prevalence of lifetime comorbidity. Prospective research is now needed to understand the long-term
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Dierker L, He J, Kalaydjian A, et al. The Importance of Timing of Transitions for
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Risk of Regular Smoking and Nicotine Dependence. Ann Behav Med. 2008;36:87-92. Armstrong T, Costello E. Community studies on adolescent substance use, abuse, or
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McGee R, Williams S, Poulton R, Moffitt T. A longitudinal study of cannabis use and mental health from adolescence to early adulthood. Addiction. 2000;95:491-503. Wittchen H, Fröhlich C, Behrendt S, et al. Cannabis use and cannabis use disorders
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Zimmermann P, Wittchen H, Höfler M, Pfister H, Kessler R, Lieb R. Primary anxiety
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2009;104:1743–1756.
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Table 1: Prevalence of Use of Alcohol and Illicit Drug Among Respondents With a Prior Mental Disorders Alcohol
na % 2486 63.2 1018 61.6
SE 2.4 2.8
Regular Use (median age=13.8)
Abuse (w/ or w/o Dependence) (median age=14.3)
na 2692 1298
na 2763 1395
SE 2.1 2.4
% 30.0 35.7
% 10.3 13.9
SE 0.9 1.3
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1st Use (median age=12.2)
Illicit Drug Having Opportunity to Use (median age=12.8) SE na % 2565 66.8 2.2 1082 70.2 2.2
Any Use (median age=13.3) na % 2704 33.7 1279 36.0
SE 2.1 2.6
Abuse (w/ or w/o Dependence) (median age=14.1) na % SE 2758 14.9 1.3 1400 19.3 1.6
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Any disorder Any mood disorder (MDD, DYS, BIP) Any phobia disorder 2191 59.4 2.2 2293 28.4 1.9 2319 8.5 0.9 2234 65.0 2.0 2300 27.6 2.1 2318 12.0 1.4 (AGP, SO, SP, SAD) Any anxiety disorder 472 67.2 3.9 582 35.6 4.5 628 17.3 3.0 505 76.7 2.9 568 39.2 3.7 613 20.0 2.3 (GAD, PAN, PTSD) Any behavior 1109 70.8 2.6 1237 41.1 3.1 1278 15.6 1.8 1134 75.8 2.5 1231 48.6 2.9 1279 24.0 1.9 disorder (ADHD, CD, ODD) Any eating disorder 187 62.1 4.7 244 32.6 4.5 270 9.7 2.0 194 62.1 4.7 244 33.2 5.9 267 18.4 4.5 (ANO, BUL, BINGE) Other conditions: Weekly smoking 672 90.7 2.0 1124 67.9 2.4 1363 25.6 2.1 664 93.8 1.6 990 74.4 2.2 1365 36.3 2.0 Illicit drug use 1197 89.8 1.4 2029 60.9 2.3 2324 21.9 1.3 Regular alcohol 1039 84.7 1.6 1748 50.2 2.3 2321 24.3 1.5 use NOTE: ADHD = attention-deficit/hyperactivity disorder; AGP = agoraphobia; ANO = anorexia nervosa; BINGE = binge eating disorder; BIP = bipolar I or II; BUL = bulimia nervosa; CD = conduct disorder; DYS = dysthymia; GAD = general anxiety disorder; MDD = major depressive disorder; ODD = oppositional defiant disorder; PAN = panic disorder; PTSD = posttraumatic stress disorder; SAD = separation anxiety disorder; SO = social phobia; SP = specific phobia. a Number of participants with the respective prior mental disorders (respondents with mental disorder occurred after onset of alcohol/drug use stage were treated as non-cases, i.e. counted in the denominator but not in numerator).
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ACCEPTED MANUSCRIPT Table 2. The Association of a Prior Mental Disorder and Transitions to Alcohol Use, Abuse, and Dependence
aOR 95% CI a 1.34 1.17 - 1.53* 2.04 1.69 - 2.45* 1.47 1.06 - 2.04*
1.52
1.30 - 1.78*
1.91
1.65 - 2.21*
2.28
1.74 - 2.98*
1.38 1.30 1.09 1.29
1.09 - 1.75* 1.04 - 1.63* 0.93 - 1.28 1.06 - 1.56
2.70 1.67 1.15 1.34
1.84 - 3.95* 1.33 - 2.11* 0.96 - 1.38 1.02 - 1.75*
1.52 2.55 1.55 1.11
0.74 - 3.11 1.81 - 3.59* 1.10 - 2.17* 0.69 - 1.78
1.17
1.03 - 1.33
1.36
1.17 - 1.58*
1.61
1.24 - 2.08*
1.14 1.17 2.04
0.79 - 1.66 0.81 - 1.69 1.66 - 2.51*
1.89 1.57 1.46
0.95 - 3.78 1.03 - 2.39* 1.04 - 2.05*
1.55 2.32 3.56
0.83 - 2.89 1.29 - 4.17* 1.93 - 6.55*
1.63
1.37 - 1.93*
1.58
1.22 - 2.06*
3.05
1.95 - 4.75*
1.34 2.50 1.98
1.12 - 1.60* 2.03 - 3.09* 1.58 - 2.48*
1.27 2.36 2.00
0.97 - 1.66 1.82 - 3.06* 1.54 - 2.60*
1.26 2.91 2.58
0.86 - 1.86 2.06 - 4.12* 1.69 - 3.96*
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1.86
1.56 - 2.22*
2.05
1.64 - 2.55*
3.26
2.26 - 4.71*
1.86
1.32 - 2.61*
1.96
1.24 - 3.09*
1.81
1.04 - 3.16*
6.65 7.68
5.39 - 8.21* 6.45 - 9.13*
5.55 6.75
4.63 - 6.66* 5.71 - 7.98*
4.51 8.07
3.26 - 6.25* 5.82 - 11.20*
1.12 1.18
0.93 - 1.36 0.80 - 1.75
1.46 0.90
1.18 - 1.80* 0.60 - 1.34
1.20 1.86
0.90 - 1.59 1.14 - 3.03*
1.15
0.94 - 1.40
1.32
1.11 - 1.57*
1.41
1.10 - 1.81*
1.34 1.00 0.99 1.16
1.06 - 1.69* 0.75 - 1.33 0.84 - 1.18 0.91 - 1.47
2.34 1.17 1.03 1.13
1.42 - 3.85* 0.89 - 1.53 0.81 - 1.32 0.79 - 1.63
1.28 1.79 1.32 0.90
0.61 - 2.72 1.25 - 2.55* 0.94 - 1.86 0.55 - 1.47
1.03
0.89 - 1.19
1.16
0.94 - 1.42
1.29
0.96 - 1.74
0.75 0.87 1.43 1.21
0.48 - 1.19 0.57 - 1.33 1.02 - 2.00* 0.96 - 1.53
1.30 0.91 0.90 1.00
0.76 - 2.24 0.53 - 1.55 0.60 - 1.35 0.72 - 1.40
0.93 1.49 2.07 1.89
0.47 - 1.83 0.76 - 2.91 1.07 - 4.02* 1.16 - 3.09*
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Model II
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MDD/Dysthymia Bipolar I/II Any mood disorder (MDD/Dys, BIP) AGP SP SO SAD Any phobia disorder (AGP, SO, SP, SAD) GAD PAN PTSD Any anxiety disorder
Regular Alcohol Use Among Users
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Any disorder MDD/Dysthymia Bipolar I/II Any mood disorder (MDD/Dys, BIP) AGP SP SO SAD Any phobia disorder (AGP, SO, SP, SAD) GAD PAN PTSD Any anxiety disorder (GAD, PAN, PTSD) ADHD CD ODD Any behavior disorder (ADHD, CD, ODD) Any eating disorder Other conditions: Weekly smoking Illicit drug use
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Model I
aOR 95% CI a 1.38 1.23 - 1.54* 1.51 1.29 - 1.77* 1.45 0.93 - 2.27
Alcohol Abuse/Dependence Among Regular Users aOR 95% CI a 1.84 1.50 - 2.25* 1.88 1.42 - 2.50* 2.93 1.86 - 4.62*
First Alcohol Use Among Non-Users
Mental Disorder
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ACCEPTED MANUSCRIPT 1.17 1.37 1.36
0.96 - 1.42 1.08 - 1.74* 1.08 - 1.71*
0.96 1.16 1.14
0.67 - 1.39 0.89 - 1.51 0.87 - 1.49
0.76 1.20 1.44
0.50 - 1.16 0.85 - 1.71 0.96 - 2.16
1.38
1.15 - 1.66*
1.21
0.97 - 1.52
1.48
1.01 - 2.15*
1.12
0.79 - 1.60
1.09
0.61 - 1.95
0.91
0.43 - 1.91
3.08 5.41
2.41 - 3.93* 4.41 - 6.64*
2.36 4.70
1.93 - 2.89* 3.91 - 5.65*
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(GAD, PAN, PTSD) ADHD CD ODD Any behavior disorder (ADHD, CD, ODD) Any eating disorder Other conditions: Weekly smoking Illicit drug use
1.89 5.39
1.38 - 2.58* 3.91 - 7.42*
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Note: ADHD = attention-deficit/hyperactivity disorder; AGP = agoraphobia; CD = conduct disorder; Dys = dysthymia; GAD = general anxiety disorder; MDD = major depressive disorder; ODD = oppositional defiant disorder; PAN = panic disorder; PTSD = posttraumatic stress disorder; SAD = separation anxiety disorder; SO = social phobia; SP = specific phobia. a Model I adjusted for age, sex, race/ethnicity; Model II additionally adjusted for any mood disorder, phobia, anxiety disorder, behavior disorder, eating disorder, weekly smoking, and illicit drug use (when a mental disorder is the covariate of interest, the specific analysis was not adjusted for this particular mental disorder class, but for all other classes of disorders). *p < .05
21
ACCEPTED MANUSCRIPT Table 3. The Association of a Prior Mental Disorder and Transitions to Drug Use, Abuse, and Dependence
MDD/Dys BIP I/II Any mood disorder (MDD/Dys, BIP) AGP SP SO SAD Any phobia disorder (AGP, SO, SP, SAD) GAD PAN PTSD Any anxiety disorder (GAD, PAN, PTSD) ADHD CD ODD Any behavior disorder (ADHD, CD, ODD) Any eating disorder
Drug Abuse/Dependence Among Drug Users aOR 95% CIa 1.82 1.52 - 2.18* 1.79 1.37 - 2.34* 2.71 1.58 - 4.65*
1.84
1.65 - 2.06*
1.74
1.42 - 2.13*
2.19
1.77 - 2.70*
1.37 1.30 1.44 1.36
1.03 - 1.83* 1.11 - 1.52* 1.15 - 1.80* 1.12 - 1.64*
0.97 1.15 1.65 1.04
0.66 - 1.44 0.97 - 1.35 1.22 - 2.22* 0.75 - 1.44
1.89 1.13 2.08 1.54
1.06 - 3.35* 0.81 - 1.58 1.29 - 3.34* 0.98 - 2.42
1.39
1.23 - 1.56*
1.21
1.03 - 1.42*
1.51
1.06 - 2.16*
1.38 1.80 2.54
0.79 - 2.40 1.21 - 2.68* 2.08 - 3.11*
1.63 1.83 1.91
0.91 - 2.90 1.17 - 2.84* 1.39 - 2.61*
1.97 1.83 2.11
0.78 - 5.01 1.15 - 2.93* 1.38 - 3.23*
2.09
1.75 - 2.50*
1.83
1.46 - 2.29*
2.17
1.60 - 2.94*
1.70 3.46 1.92
1.43 - 2.01* 2.75 - 4.36* 1.54 - 2.40*
1.92 4.29 2.98
1.48 - 2.50* 3.38 - 5.45* 2.14 - 4.14*
1.47 3.90 2.04
0.98 - 2.21 2.74 - 5.54* 1.39 - 3.00*
2.21
1.88 - 2.60*
3.62
3.04 - 4.33*
2.89
2.02 - 4.13*
2.01
1.35 - 2.98*
1.83
0.95 - 3.53
2.20
1.16 - 4.16*
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Model II
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Drug Use Among Those Having Opportunity aOR 95% CIa 1.72 1.49 - 1.98* 1.71 1.37 - 2.14* 1.64 1.23 - 2.18*
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Any disorder MDD/Dys BIP I/II Any mood disorder (MDD/Dys, BIP) AGP SP SO SA Any phobia disorder (AGP, SO, SP, SAD) GAD PAN PTSD Any anxiety disorder (GAD, PAN, PTSD) ADHD CD ODD Any behavior disorder (ADHD, CD, ODD) Any eating disorder Other conditions: Weekly smoking Regular alcohol use
Opportunity to Use Drugs Among NonUsers aOR 95% CIa 1.46 1.29 - 1.65* 1.95 1.72 - 2.22* 1.43 0.90 - 2.28
9.06 4.82
6.86 - 11.96* 3.97 - 5.84*
7.54 4.01
6.32 - 8.99* 3.34 - 4.81*
4.18 3.73
3.17 - 5.51* 2.89 - 4.81*
1.35 1.10
1.16 - 1.56* 0.74 - 1.64
1.20 1.06
0.96 - 1.50 0.79 - 1.43
1.12 1.92
0.85 - 1.48 1.15 - 3.21*
1.30
1.13 - 1.49*
1.17
0.95 - 1.45
1.39
1.12 - 1.73*
1.11 1.16 1.11 1.13
0.81 - 1.52 0.97 - 1.38 0.85 - 1.44 0.92 - 1.40
0.82 1.00 1.24 0.81
0.55 - 1.23 0.81 - 1.24 0.89 - 1.73 0.56 - 1.17
1.48 0.97 1.87 1.13
0.78 - 2.79 0.73 - 1.29 1.35 - 2.60* 0.69 - 1.84
1.20
1.04 - 1.39*
1.00
0.82 - 1.22
1.23
0.88 - 1.71
1.06 1.42 1.91
0.61 - 1.83 1.01 - 2.00* 1.47 - 2.48*
1.13 1.45 1.25
0.57 - 2.22 0.89 - 2.38 0.84 - 1.86
1.16 1.40 1.27
0.32 - 4.18 0.87 - 2.27 0.85 - 1.90
1.64
1.35 - 1.99*
1.28
0.99 - 1.65
1.41
1.05 - 1.88*
1.41 2.43 1.39
1.13 - 1.76* 1.91 - 3.08* 1.12 - 1.73*
1.65 3.24 2.21
1.29 - 2.12* 2.56 - 4.10* 1.65 - 2.97*
1.13 2.52 1.50
0.78 - 1.64 1.84 - 3.46* 1.16 - 1.95*
1.66
1.39 - 1.98*
2.82
2.38 - 3.32*
1.85
1.34 - 2.54*
1.39
0.83 - 2.34
1.44
0.88 - 2.38
1.59
0.87 - 2.93
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Model I
Mental Disorder
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6.64 3.69
4.77 - 9.24* 3.05 - 4.46*
5.46 2.97
4.44 - 6.71* 2.43 - 3.62*
2.83 2.67
2.16 - 3.72* 2.08 - 3.44*
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Note: ADHD = attention-deficit/hyperactivity disorder; AGP = agoraphobia; BIP = bipolar disorder; CD = conduct disorder; Dys = dysthymia; GAD = general anxiety disorder; MDD = major depressive disorder; ODD = oppositional defiant disorder; PAN = panic disorder; PTSD = posttraumatic stress disorder; SAD = separation anxiety disorder; SO = social phobia; SP = specific phobia. a Model I adjusted for age, sex, race/ethnicity; Model II additionally adjusted for any mood disorder, phobia, anxiety disorder, behavior disorder, eating disorder, weekly smoking, and regular alcohol use (when a mental disorder is the covariate of interest, the specific analysis was not adjusted for this particular mental disorder class, but for all other classes of disorders). *p < .05
23
S0890-8567(16)00070-8
DOI:
10.1016/j.jaac.2016.01.006
Reference:
JAAC 1367
To appear in:
Journal of the American Academy of Child & Adolescent Psychiatry
Received Date: 11 September 2015 Revised Date:
4 January 2016
Accepted Date: 10 January 2016
Please cite this article as: Conway KP, Swendsen J, Husky MM, He J-P, Merikangas KR, Association of Lifetime Mental Disorders and Subsequent Alcohol and Illicit Drug use: Results from the National Comorbidity Survey–Adolescent Supplement, Journal of the American Academy of Child & Adolescent Psychiatry (2016), doi: 10.1016/j.jaac.2016.01.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Association of Lifetime Mental Disorders and Subsequent Alcohol and Illicit Drug Use: Results From the National Comorbidity Survey-Adolescent Supplement RH: Substance Use and Comorbidity Kevin P. Conway, PhD; Joel Swendsen, PhD; Mathilde M. Husky, PhD; Jian-Ping He, MS; Kathleen R. Merikangas, PhD This article is discussed in an editorial by Dr. Karen Abram on page xx.
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Accepted January 28, 2016
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Dr. Conway is with the Division of Epidemiology, Services and Prevention Research at the National Institute on Drug Abuse (NIDA), Rockville, MD. Dr. Swendsen is with the École Pratique des Hautes Études (EPHE), Paris, the National Center for Scientific Research (CNRS), Paris, and University of Bordeaux, France. Dr. Husky is with the University of Paris Descartes, Paris. Dr. Merikangas and Ms. He are with the Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health (NIMH), Bethesda, MD.
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This work was supported by the Intramural Research Program of the National Institute of Mental Health (Z01MH002808-08). The National Comorbidity Survey Adolescent Supplement (NCS-A) and the larger program of related NCS surveys are supported by the National Institute of Mental Health (U01-MH60220). The views and opinions expressed in this article are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or US government. Ms. He served as the statistical expert for this research.
Disclosure: Drs. Conway, Swendsen, Husky, Merikangas, and Ms. He report no biomedical financial interests or potential conflicts of interest.
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Correspondence to Kathleen Ries Merikangas, PhD, Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health, 35 Convent Drive, MSC #3720 Bethesda, MD 20892; email: [email protected].
ACCEPTED MANUSCRIPT ABSTRACT Objective: To estimate the association of prior lifetime mental disorders with transitions across stages of substance use in a cross-sectional, nationally representative sample of US adolescents.
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Method: The sample includes 10,123 adolescents aged 13-18 who participated in the
National Comorbidity Survey–Adolescent Supplement (NCS-A), and who were directly
interviewed with the Composite International Diagnostic Interview (CIDI) Version 3.0 that
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generates criteria for DSM-IV disorders.
Results: Adolescents with prior lifetime mental disorders had high rates of both alcohol
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(10.3%) and illicit drug (14.9%) abuse with or without dependence. Alcohol and drug abuse were highest among adolescents with prior anxiety disorders (17.3% and 20%, respectively) and behavior disorders (15.6% and 24%, respectively). Any prior disorder significantly increased the risk of transition from non-use to first use, and from use to problematic use of
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either alcohol or illicit drugs. Multivariate models attenuated the magnitude of the risk of transition associated with each disorder, though prior weekly smoking and illicit drug use demonstrated significant risks of transitions across the three stages of alcohol or drug use, as
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did behavior disorders.
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Conclusion: The findings provide the first evidence from a nationally representative sample that prior mental disorders represent risk factors for the transition from non-use to use, and the progression to drug- and alcohol-related problems. Treatment of primary mental disorders is likely to be an important target for the prevention of secondary substance use disorders in youth. Key words: adolescence, alcohol use, comorbidity, drug use, epidemiology INTRODUCTION
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ACCEPTED MANUSCRIPT Nationally representative surveys of substance use disorders (SUDs) in adults1-3 have generated lifetime rates of SUDs that are only moderately higher than those among adolescents.4-8 This suggests that the majority of lifetime cases of SUDs have their onset in mid to late adolescence. However, while over three decades of research in psychiatric
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epidemiology have shown that the prevalence of these conditions varies considerably by sociodemographic characteristics and co-occurring mental disorders, few nationally
representative samples of American adolescents have systematically investigated the impact
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of prior mental disorders on multiple stages of substance use.1,7-12
The numerous of studies of adults consistently suggest that a history of mental
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disorders is a salient risk factor for diverse forms of SUDs.13-19 Although “forward telescoping” and other memory biases may reduce the reliability of such estimates,20 the tenyear follow-up of the National Comorbidity Survey, as well as the two-wave analyses of the National Epidemiologic Survey on Alcohol and Related Conditions, has confirmed the
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prospective risk posed by primary mental disorders.21-25 The etiologic importance of these associations is particularly relevant to youth in light of findings that most mental disorders, including the major categories of mood, anxiety, behavior, and eating disorders, each have an
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average earlier age of onset than SUDs.26
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Among the important advances in understanding the etiology of the substance use disorders among adults is the finding that risk factors may differ substantially by stage of substance use. In particular, the associations between common sociodemographic factors (such as sex or race) with both alcohol and illicit drug dependence have been shown to vary according to specific stages of use.2,3,27-29 The associations observed for prior mental disorders in adults have also been shown to vary according to stage of substance use, as well as by mental disorder type. 22 Research that clarifies the role and timing of prior mental
1
ACCEPTED MANUSCRIPT disorders across substance use stages therefore holds promise for optimizing interventions designed to prevent substance use disorders. The existing regional or community studies have shown that the majority of youth with alcohol or drug use disorders have comorbid conduct disorder, oppositional defiant
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disorder, or depression30, and also that prior psychiatric conditions during adolescence predict substance use disorders later in life31-35 with some evidence of differential effects as a
function of gender and age.36 While nationally representative surveys conducted in the United
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States have also provided rich information concerning risk factors for substance use in
adolescents, notably including the National Survey on Drug Use and Health4,7,9, the National
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Health and Nutrition Examination Survey5, and the Monitoring the Future project6,8, the association of mental disorders with the risk of transition across the different stages of substance use has been conducted almost exclusively with adult samples. To address these concerns, the current study examines this topic in the National Comorbidity Survey –
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Adolescent Supplement (NCS-A), a nationally representative survey of youth aged 13 to 18 years conducted between February 2001 and January 2004. Using direct diagnostic interviews, information was collected for a large number of mental disorders as well as for
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diverse stages of alcohol and drug use, ranging from first opportunity to use substances, to
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abuse, and abuse with dependence. The objectives of the present investigation are to: (1) estimate the association among prior mental disorders among adolescents with the different stages of alcohol and illicit drug use; and (2) estimate the association between prior mental disorders and the probability of transition from earlier to later stages of use. METHOD Sample and Procedure The NCS-A is a cross-sectional, nationally representative face-to-face survey of 10,123 adolescents aged 13-18 years in the continental US.37 The survey was administered
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ACCEPTED MANUSCRIPT by trained lay interviewers from the Institute for Social Research at the University of Michigan. The NCS-A was carried out in a dual-frame sample that included a household subsample and a school subsample. 38-40 The overall NCS-A adolescent response rate combining the two subsamples was 82.9%. The recruitment and consent procedures were
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approved by the human subjects committees of both Harvard Medical School and the University of Michigan.
Comparisons of sample and population distributions on census sociodemographic
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variables, and in the school sample on school characteristics, documented only minor
differences that were corrected with post-stratification weighting. Once the survey was
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completed, cases were weighted for variation in within-household probability of selection (in the household subsample) and for residual discrepancies between the sample and the US population on the basis of sociodemographic and geographic variables. These weighting procedures are discussed in more detail elsewhere.38,39
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Sociodemographic variables examined in this report include age (in years), sex, and race/ethnicity. About half the sample was male (51.3%), and the mean age was 15.2 years, with a larger proportion of youth aged 13-14 years (36.2%), and approximately equal
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distributions of youth aged 15, 16, and 17-18 years. The sample was comprised of 65.6%
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non-Hispanic whites, 15.1% non-Hispanic blacks, and 14.4% Hispanics. Measures
Diagnostic assessment. Details of the diagnostic and risk factor measures are described
by Merikangas et al. 37 Briefly, adolescents were administered a modified version of the World Health Organization (WHO) Composite International Diagnostic Interview Version 3.0 (CIDI), a fully structured interview administered by trained lay interviewers to generate DSM-IV diagnoses.41 For the purpose of this investigation, age of onset of a lifetime mental disorder was defined as the age at which the individual met full diagnostic criteria for that disorder,
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ACCEPTED MANUSCRIPT grouped into five main categories including mood disorders (major depression or dysthymia, bipolar I or II disorder), phobia disorders (agoraphobia, social phobia, specific phobia, and separation anxiety disorder), anxiety disorders (generalized anxiety disorder, panic disorder, posttraumatic stress disorder [PTSD]), behavior disorders (attention-deficit/hyperactivity
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disorder [ADHD], conduct disorder, oppositional defiant disorder), and eating disorders
(anorexia, bulimia, binge eating disorder). Lifetime substance use disorders included alcohol and drug abuse, and individuals fulfilling abuse criteria were administered questions
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concerning dependence. In this way, instances of alcohol and drug dependence without a
history of abuse were not assessed. This report therefore presents both categories of abuse (with
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or without dependence). In addition to DSM-IV diagnoses, all respondents were asked about their use of diverse substances and the age at which specific stages of use first occurred. Adolescent self-reports of substance use have been found to have good concordance with parental reports.42 For alcohol, the lifetime use question concerned age at which respondents
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first (if ever) had a drink with alcohol, specified as beer, wine, wine coolers, and hard liquor (such as vodka, gin, whiskey, and mixed drinks). First regular use of alcohol was defined as the age at which the respondent first had at least 12 drinks within a single year as a proxy for non-
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experimental alcohol use that approximated monthly use. For illicit drugs, participants were
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asked the age at which they had first (if ever) consumed a range of specific substances, including marijuana or hashish; cocaine in any form (e.g. powder, crack, free base, coca leaves, or paste); tranquilizers, stimulants, pain killers, or other prescription drugs either without the recommendation of a health professional, or for any reason other than a health professional said they should be used; heroin, opium, glue, LSD, peyote, or any other drug. Participants were also asked about the first time they had an opportunity to drink alcohol or to use drugs, regardless of whether or not they used them. Opportunity to use was defined as when someone either offered them alcohol or drugs, or when the individual was present when others were
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ACCEPTED MANUSCRIPT using and could have used if he or she wanted to. The age of first opportunity to use substances was recorded separately for alcohol and drugs. In light of the very high availability of legal substances such as alcohol, only opportunity to use illicit drugs is examined in this investigation.
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Statistical Analysis
Cross-tabulations were used to calculate the prevalence of lifetime mental disorders having an onset at least one year prior to the onset of the different stages of alcohol and drug
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use. Conditional prevalence estimates for each alcohol or drug use stage were also calculated among those who had reached the earlier stage of use. Estimated projections of the
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cumulative probability of stages of alcohol or drug use as of age 18 were obtained by the actuarial method implemented in PROC LIFETEST in SAS (Version 9.2, SAS Institute). Predictors of transitions across the alcohol or drug stages were examined using discrete-time survival analysis using the logit function with person-year as the unit of analysis43. The
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person-year data array used in the transition from no use to first use of alcohol (or opportunity to use illicit drug) includes all years in the life of the respondents prior to and including their age at having their first alcoholic drink (or having opportunity to use illicit
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drug). The person-year data array for the following two stages of analysis (ever use to
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regular use, regular use to abuse/dependence for alcohol stages; having opportunity to use to any use, any use to abuse/dependent for illicit drug use stages) include all years beginning with the year after the earlier transition and continuing through the year of onset of the next transition or, for respondents who never made the next transition, through their age at interview. The associations of prior mental disorders with the stages of alcohol or drug use were examined in the survival model I series controlling for age, sex, and race/ethnicity. These associations were further examined when additionally adjusting for mental disorders in survival model II series. As the NCS-A data are both clustered and weighted, the Taylor
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ACCEPTED MANUSCRIPT series linearization method 44 implemented in SUDAAN (version 10, Research Triangle Institute) was used to estimate standard errors of logistic regression coefficients. The coefficients and standard errors were exponentiated to produce odds ratios (ORs) and 95% CIs. Significance of predictor sets was evaluated using Wald Chi-Square tests based on
consistently evaluated using .05-level two-sided tests. RESULTS
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design-adjusted coefficient variance-covariance matrices. Statistical significance was
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Prevalence of Alcohol and Drug Use Stages Among Adolescents With Prior Mental Disorders
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A total of 37.7% of adolescents experienced at least one mental disorder before the first use of alcohol, 47.6% before regular alcohol use, 66.6% before alcohol abuse with or without dependence. The percentage of adolescents for whom the prior disorder persisted into the year of onset for each of these stages was respectively 11.3%, 9.4%, and 7.8%. For drug
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use categories, 41.2% of adolescents met criteria for at least one mental disorder before having the opportunity to use drugs, 53.8% before first drug use, and 66.8% before drug abuse with or without dependence. The persistence of prior disorders into the same year of
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onset for these categories was respectively 9.5%, 10.5%, and 9.1%.
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By age 18, the majority of adolescents with pre-existing mental disorders had consumed alcohol at least once and had reported having the opportunity to use drugs. Furthermore, by this age, approximately one-third of all adolescents with mental disorders had become regular drinkers of alcohol or had used illicit drugs (Table 1). Adolescents with mental disorders also had high rates of both alcohol abuse with or without dependence (10.3%) and illicit drug abuse with or without dependence (14.9%). Regarding specific mental disorders, higher rates across the stages of alcohol and illicit drug use were typically observed for adolescents with anxiety or behavior disorders, whereas the lowest rates were
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ACCEPTED MANUSCRIPT observed for individuals with phobia or eating disorders. In particular, the rates for alcohol abuse with or without dependence were much higher among adolescents with prior anxiety disorders (17.3%) and behavior disorders (15.6%) than their counterparts with prior phobia disorders (8.5%) or eating disorders (9.7%). Nearly a quarter (24%) of adolescents with a
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prior behavior disorder and 20% of adolescents with an anxiety disorder developed illicit drug abuse with or without dependence, compared to 12% of adolescents with phobia
disorders. Notably, prior use of other substances was strongly associated with the stages of
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alcohol and drug use. Adolescents who already reached weekly smoking levels or who had previously used illicit drugs reported the highest rates of alcohol use, regular use, and abuse
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with or without dependence. In turn, those who had reached weekly smoking levels or regularly used alcohol had the highest rates of illicit drug use opportunity, drug use, and drug abuse with or without dependence.
Prior Mental Disorder as Predictor of Transition Across Alcohol Use Stages
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The association between prior mental disorders and the transitions from one stage of alcohol use to another was examined first for any class of mental disorder, adjusting for age, sex, and race/ethnicity (Table 2, Model I). Results show that having any prior mental disorder
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significantly increased the risk across the three transitions: from non-use to use of alcohol
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(OR=1.38), from use to regular alcohol use (OR=1.34), and from regular use to alcohol abuse with or without dependence (OR=1.84). Concerning the risk associated with specific mental disorders, we observed increased risk of transition to all three stages of alcohol use as a function with prior major depression/dysthymia (ORs= 1.51, 2.04, 1.88), specific phobia (ORs= 1.30, 1.67, 2.55), PTSD (ORs= 2.04, 1.46, 3.56), conduct disorder (ORs= 2.50, 2.36, 2.91), oppositional defiant disorder (ORs= 1.98, 2.00, 2.58), and eating disorders (ORs= 1.81,1.96, 1.81). With the exception of generalized anxiety disorder, all other specific disorders demonstrated a significantly higher risk of transition to at least one stage. Prior
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ACCEPTED MANUSCRIPT substance use was a robust risk factor for each stage of alcohol use, as both prior weekly smoking (ORs =6.65, 5.55, 4.51) and illicit drug use (ORs= 7.68, 6.75, 8.07) were associated with increased risk at each stage of alcohol use, respectively. In light of the substantial lifetime comorbidity observed for individuals with prior
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mental disorders, multivariate analyses were also performed with adjustments for all
comorbid disorders (Table 2, Model II). In these models, only prior weekly smoking and illicit drug use demonstrated significant risks of transitions across the three stages of alcohol
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use (ORs =3.08, 2.36, 1.89 for weekly smoking, respectively; and ORs=5.41, 4.70, 5.39 for illicit drug use, respectively) and most of the associations for classes or specific disorders
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were attenuated and non-significant. The risk posed by behavior disorders was most evident for initial transition to alcohol use (with the exception of ADHD, which was unrelated to any stage), although any behavioral disorder was also associated with the transition to abuse with or without dependence. In contrast to behavior disorders, mood disorders were more salient
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in later stages. More disparate effects were observed for phobia and anxiety disorders, with agoraphobia having a greater impact on earlier transitions, specific phobia on the transition to
stages.
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abuse with or without dependence, and with PTSD influencing transitions to the first and last
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Prior Mental Disorder as Predictor of Transition Across Drug Use Stages The associations between prior mental disorders and the transitions across drug use
stages were highly similar to those observed for alcohol stages (Table 3, Model I). The aggregate category of any prior mental disorder was significantly associated with the probability of transition across each stage of drug use and with increasing magnitude of risk across each subsequent stage. Similarly, for specific mental disorders, we found that having a prior mental disorder posed increased risk across all three stages for major depression/dysthymia (ORs= 1.95, 1.71, 1.79), social phobia (ORs= 1.44, 1.65, 2.08), panic
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ACCEPTED MANUSCRIPT disorder (ORs= 1.80, 1.83, 1.83), PTSD (ORs= 2.54, 1.91, 2.11), conduct disorder (ORs= 3.46, 4.29, 3.90), and oppositional defiant disorder (ORs= 1.92, 2.98, 2.04). Prior substance use was similarly a strong risk factor for each stage of drug use for both weekly smoking (ORs=9.06, 7.54, 4.18) and regular alcohol use (ORs=4.82, 4.01, 3.73). In contrast to
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findings for alcohol stages, however, the magnitude of risk associated with phobia disorders was generally greater in transitions to earlier than in later stages of drug use. Concerning multivariate analyses adjusting for other mental disorders (Table 3, Model II), prior substance
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use was robustly associated with the greatest risk of all transitions across drug use stages (ORs =6.64, 5.46, 2.83 for prior weekly smokers; ORs=3.69, 2.97, 2.67 for prior regular
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alcohol users). While attenuation was again observed for most classes of disorder, the magnitude of risk for transitions across the three stages remained highly significant for conduct disorder and oppositional defiant disorder. ADHD was significantly associated with the risk of having opportunities to use drugs (OR = 1.14) and drug use (OR = 1.65), but not
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drug abuse with or without dependence.
DISCUSSION
Despite converging evidence that most lifetime cases of substance use disorders are
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likely to begin in adolescence1,5,7,45 and that prior mental disorders constitute a major risk
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factor for these conditions,22-25,30-35 the majority of information for these forms of lifetime comorbidity in nationally representative samples has been acquired from adult respondents. Moreover, information on patterns of substance use in representative samples of adolescents has generally been limited to examining risk factors for specific stages of use, rather than examining predictors of transitions from one stage of use to another. The present investigation used data from the NCS-A to examine the association of a comprehensive range of mental and substance use disorders across the full adolescent age span in a nationally representative sample. The findings confirm that the burden of substance use disorders in
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ACCEPTED MANUSCRIPT adolescence is disproportionately concentrated among youth with prior mental disorders, and that this burden is not limited to treated samples. The risk posed by prior mental disorders also varied considerably by stages of substance use. Previous analyses of this sample indicated a prevalence estimate of 6.5% for alcohol
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abuse (with or without dependence) and 8.9% for drug abuse.1 The present study documents higher estimates of these same disorders (10.3% and 14.9%, respectively) among youth with prior mental disorders. This increase in risk was particularly strong for non-phobic anxiety
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disorders and behavior disorders for which the estimates were often three-fold higher than adolescent population estimates. In particular, alcohol and drug abuse was observed in 17.3%
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and 20%, respectively, of youth with prior anxiety disorders, and in 15.6% and 24% of youth with behavior disorders. The greatest overall risk for substance use disorders was associated with having progressed to more advanced stages of use of other substances (illicit drug use, and regular alcohol or tobacco use). While the reasons underlying the differential magnitude
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of association observed for specific prior disorders cannot be confirmed by the present methods, it is possible that they reflect diverse mechanisms of association. For example, alcohol has been shown to be used as a means of assuaging symptoms of anxiety disorders24
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and therefore its pharmacologic effects may explain why alcohol abuse was highest among
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adolescents with anxiety disorders than for any other comorbid condition. By contrast, the high concentration of illicit drug abuse among respondents with behavior disorders may reflect social or personality factors, such as the perceived deviance of the substance used, rather than a match between its pharmacologic effects and the psychiatric symptoms experienced by the individual.46. Although there has been substantial research identifying risk factors for aggregate substance use disorders, there is increasing evidence for differential risk for different stages of use. For example, investigations of adult samples have found that the association of both
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ACCEPTED MANUSCRIPT sociodemographic risk factors and prior mental disorders is often concentrated at very specific stages of the substance use trajectory, and that the nature of risk may even reverse for other stages.2,3,22,27-29 In the present study, the presence of any prior mental disorder was associated with greater probability of transition to initial use, to regular use, and to abuse with
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or without dependence. Bivariate models indicated that most individual disorders were associated with the risk for transition across several of these stages. However, the
multivariate models that account for lifetime comorbidity among the mental disorders
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demonstrated that the behavior disorders were associated with a stronger risk of initial
alcohol use, whereas mood or anxiety disorders had a stronger risk in transitions to regular
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use or to abuse with or without dependence. These patterns were different for drug use stages, where mood disorders (notably depression) and anxiety or phobic disorders had stronger associations on the risk of initial opportunity to use drugs, whereas behavior disorders had a generally significant and constant association across all stages of drug use. The lack of an
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independent association between ADHD and substance use concurs with other studies demonstrating the important mediating role of other comorbid behavior disorders.47 Whether for alcohol or for illicit drugs, both the unconditional and conditional models demonstrated
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comprehensively greater risk for transition to each stage if the adolescent had already attained
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more advanced stages of use of another substance. It is also important to note that the association of mental disorders with a given stage of substance use may reflect social processes (e.g., self-selection into peer groups) involving individual behavior or characteristics (e.g., depression),48 as well as broader factors that may affect parental monitoring due to the concentration of mental disorders within families.16 The strengths of this study include its use of comprehensive in-person diagnostic interviews that permit the assessment of a wide range of mental disorders and their association with different stages of substance use. Its application in a nationally
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ACCEPTED MANUSCRIPT representative sample spanning the entire adolescent age range also complements data acquired from other surveys of US youth concerning the role of mental disorders30 and extends findings from adults in the parallel NCS replication (NCS-R) study2,3 to earlier stages of development. Its limitations include the cross-sectional nature of the data and reliance of
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retrospective dating of disorder onset. While the assessment of such events in youth for
conditions that had occurred typically within a limited number of years should be less prone to bias than retrospective assessments in adults that may span several decades, forward
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telescoping and other memory biases cannot be excluded. In addition, this investigation
provided assessments of alcohol or illicit drug dependence only among youth meeting criteria
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for abuse, thereby ignoring individuals who experienced substance dependence alone. While this gated approach has been shown to have little impact on the magnitude or patterns of risk factors for substance use disorders,49 it likely reduces estimates for the overall prevalence of lifetime comorbidity. Prospective research is now needed to understand the long-term
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Tuithof M, ten Have M, van den Brink W, Vollebergh W, de Graaf R. The role of
SC
47.
conduct disorder in the association between ADHD and alcohol use (disorder).
M AN U
Results from the Netherlands Mental Health Survey and Incidence Study-2. Drug Alcohol Depend. 2012;123:115-21. 48.
Audrain-McGovern J, Rodriguez D, Kassel JD. Adolescent smoking and depression: Evidence for self-medication and peer smoking mediation. Addiction.
Degenhardt L, Cheng H, Anthony J. Assessing cannabis dependence in community
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surveys: methodological issues. Int J Methods Psychiatr Res. 2007;16:43-51.
AC C
49.
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2009;104:1743–1756.
18
ACCEPTED MANUSCRIPT
Table 1: Prevalence of Use of Alcohol and Illicit Drug Among Respondents With a Prior Mental Disorders Alcohol
na % 2486 63.2 1018 61.6
SE 2.4 2.8
Regular Use (median age=13.8)
Abuse (w/ or w/o Dependence) (median age=14.3)
na 2692 1298
na 2763 1395
SE 2.1 2.4
% 30.0 35.7
% 10.3 13.9
SE 0.9 1.3
RI PT
1st Use (median age=12.2)
Illicit Drug Having Opportunity to Use (median age=12.8) SE na % 2565 66.8 2.2 1082 70.2 2.2
Any Use (median age=13.3) na % 2704 33.7 1279 36.0
SE 2.1 2.6
Abuse (w/ or w/o Dependence) (median age=14.1) na % SE 2758 14.9 1.3 1400 19.3 1.6
AC C
EP
TE D
M AN U
SC
Any disorder Any mood disorder (MDD, DYS, BIP) Any phobia disorder 2191 59.4 2.2 2293 28.4 1.9 2319 8.5 0.9 2234 65.0 2.0 2300 27.6 2.1 2318 12.0 1.4 (AGP, SO, SP, SAD) Any anxiety disorder 472 67.2 3.9 582 35.6 4.5 628 17.3 3.0 505 76.7 2.9 568 39.2 3.7 613 20.0 2.3 (GAD, PAN, PTSD) Any behavior 1109 70.8 2.6 1237 41.1 3.1 1278 15.6 1.8 1134 75.8 2.5 1231 48.6 2.9 1279 24.0 1.9 disorder (ADHD, CD, ODD) Any eating disorder 187 62.1 4.7 244 32.6 4.5 270 9.7 2.0 194 62.1 4.7 244 33.2 5.9 267 18.4 4.5 (ANO, BUL, BINGE) Other conditions: Weekly smoking 672 90.7 2.0 1124 67.9 2.4 1363 25.6 2.1 664 93.8 1.6 990 74.4 2.2 1365 36.3 2.0 Illicit drug use 1197 89.8 1.4 2029 60.9 2.3 2324 21.9 1.3 Regular alcohol 1039 84.7 1.6 1748 50.2 2.3 2321 24.3 1.5 use NOTE: ADHD = attention-deficit/hyperactivity disorder; AGP = agoraphobia; ANO = anorexia nervosa; BINGE = binge eating disorder; BIP = bipolar I or II; BUL = bulimia nervosa; CD = conduct disorder; DYS = dysthymia; GAD = general anxiety disorder; MDD = major depressive disorder; ODD = oppositional defiant disorder; PAN = panic disorder; PTSD = posttraumatic stress disorder; SAD = separation anxiety disorder; SO = social phobia; SP = specific phobia. a Number of participants with the respective prior mental disorders (respondents with mental disorder occurred after onset of alcohol/drug use stage were treated as non-cases, i.e. counted in the denominator but not in numerator).
19
ACCEPTED MANUSCRIPT Table 2. The Association of a Prior Mental Disorder and Transitions to Alcohol Use, Abuse, and Dependence
aOR 95% CI a 1.34 1.17 - 1.53* 2.04 1.69 - 2.45* 1.47 1.06 - 2.04*
1.52
1.30 - 1.78*
1.91
1.65 - 2.21*
2.28
1.74 - 2.98*
1.38 1.30 1.09 1.29
1.09 - 1.75* 1.04 - 1.63* 0.93 - 1.28 1.06 - 1.56
2.70 1.67 1.15 1.34
1.84 - 3.95* 1.33 - 2.11* 0.96 - 1.38 1.02 - 1.75*
1.52 2.55 1.55 1.11
0.74 - 3.11 1.81 - 3.59* 1.10 - 2.17* 0.69 - 1.78
1.17
1.03 - 1.33
1.36
1.17 - 1.58*
1.61
1.24 - 2.08*
1.14 1.17 2.04
0.79 - 1.66 0.81 - 1.69 1.66 - 2.51*
1.89 1.57 1.46
0.95 - 3.78 1.03 - 2.39* 1.04 - 2.05*
1.55 2.32 3.56
0.83 - 2.89 1.29 - 4.17* 1.93 - 6.55*
1.63
1.37 - 1.93*
1.58
1.22 - 2.06*
3.05
1.95 - 4.75*
1.34 2.50 1.98
1.12 - 1.60* 2.03 - 3.09* 1.58 - 2.48*
1.27 2.36 2.00
0.97 - 1.66 1.82 - 3.06* 1.54 - 2.60*
1.26 2.91 2.58
0.86 - 1.86 2.06 - 4.12* 1.69 - 3.96*
RI PT
SC
1.86
1.56 - 2.22*
2.05
1.64 - 2.55*
3.26
2.26 - 4.71*
1.86
1.32 - 2.61*
1.96
1.24 - 3.09*
1.81
1.04 - 3.16*
6.65 7.68
5.39 - 8.21* 6.45 - 9.13*
5.55 6.75
4.63 - 6.66* 5.71 - 7.98*
4.51 8.07
3.26 - 6.25* 5.82 - 11.20*
1.12 1.18
0.93 - 1.36 0.80 - 1.75
1.46 0.90
1.18 - 1.80* 0.60 - 1.34
1.20 1.86
0.90 - 1.59 1.14 - 3.03*
1.15
0.94 - 1.40
1.32
1.11 - 1.57*
1.41
1.10 - 1.81*
1.34 1.00 0.99 1.16
1.06 - 1.69* 0.75 - 1.33 0.84 - 1.18 0.91 - 1.47
2.34 1.17 1.03 1.13
1.42 - 3.85* 0.89 - 1.53 0.81 - 1.32 0.79 - 1.63
1.28 1.79 1.32 0.90
0.61 - 2.72 1.25 - 2.55* 0.94 - 1.86 0.55 - 1.47
1.03
0.89 - 1.19
1.16
0.94 - 1.42
1.29
0.96 - 1.74
0.75 0.87 1.43 1.21
0.48 - 1.19 0.57 - 1.33 1.02 - 2.00* 0.96 - 1.53
1.30 0.91 0.90 1.00
0.76 - 2.24 0.53 - 1.55 0.60 - 1.35 0.72 - 1.40
0.93 1.49 2.07 1.89
0.47 - 1.83 0.76 - 2.91 1.07 - 4.02* 1.16 - 3.09*
EP
Model II
AC C
MDD/Dysthymia Bipolar I/II Any mood disorder (MDD/Dys, BIP) AGP SP SO SAD Any phobia disorder (AGP, SO, SP, SAD) GAD PAN PTSD Any anxiety disorder
Regular Alcohol Use Among Users
M AN U
Any disorder MDD/Dysthymia Bipolar I/II Any mood disorder (MDD/Dys, BIP) AGP SP SO SAD Any phobia disorder (AGP, SO, SP, SAD) GAD PAN PTSD Any anxiety disorder (GAD, PAN, PTSD) ADHD CD ODD Any behavior disorder (ADHD, CD, ODD) Any eating disorder Other conditions: Weekly smoking Illicit drug use
TE D
Model I
aOR 95% CI a 1.38 1.23 - 1.54* 1.51 1.29 - 1.77* 1.45 0.93 - 2.27
Alcohol Abuse/Dependence Among Regular Users aOR 95% CI a 1.84 1.50 - 2.25* 1.88 1.42 - 2.50* 2.93 1.86 - 4.62*
First Alcohol Use Among Non-Users
Mental Disorder
20
ACCEPTED MANUSCRIPT 1.17 1.37 1.36
0.96 - 1.42 1.08 - 1.74* 1.08 - 1.71*
0.96 1.16 1.14
0.67 - 1.39 0.89 - 1.51 0.87 - 1.49
0.76 1.20 1.44
0.50 - 1.16 0.85 - 1.71 0.96 - 2.16
1.38
1.15 - 1.66*
1.21
0.97 - 1.52
1.48
1.01 - 2.15*
1.12
0.79 - 1.60
1.09
0.61 - 1.95
0.91
0.43 - 1.91
3.08 5.41
2.41 - 3.93* 4.41 - 6.64*
2.36 4.70
1.93 - 2.89* 3.91 - 5.65*
RI PT
(GAD, PAN, PTSD) ADHD CD ODD Any behavior disorder (ADHD, CD, ODD) Any eating disorder Other conditions: Weekly smoking Illicit drug use
1.89 5.39
1.38 - 2.58* 3.91 - 7.42*
AC C
EP
TE D
M AN U
SC
Note: ADHD = attention-deficit/hyperactivity disorder; AGP = agoraphobia; CD = conduct disorder; Dys = dysthymia; GAD = general anxiety disorder; MDD = major depressive disorder; ODD = oppositional defiant disorder; PAN = panic disorder; PTSD = posttraumatic stress disorder; SAD = separation anxiety disorder; SO = social phobia; SP = specific phobia. a Model I adjusted for age, sex, race/ethnicity; Model II additionally adjusted for any mood disorder, phobia, anxiety disorder, behavior disorder, eating disorder, weekly smoking, and illicit drug use (when a mental disorder is the covariate of interest, the specific analysis was not adjusted for this particular mental disorder class, but for all other classes of disorders). *p < .05
21
ACCEPTED MANUSCRIPT Table 3. The Association of a Prior Mental Disorder and Transitions to Drug Use, Abuse, and Dependence
MDD/Dys BIP I/II Any mood disorder (MDD/Dys, BIP) AGP SP SO SAD Any phobia disorder (AGP, SO, SP, SAD) GAD PAN PTSD Any anxiety disorder (GAD, PAN, PTSD) ADHD CD ODD Any behavior disorder (ADHD, CD, ODD) Any eating disorder
Drug Abuse/Dependence Among Drug Users aOR 95% CIa 1.82 1.52 - 2.18* 1.79 1.37 - 2.34* 2.71 1.58 - 4.65*
1.84
1.65 - 2.06*
1.74
1.42 - 2.13*
2.19
1.77 - 2.70*
1.37 1.30 1.44 1.36
1.03 - 1.83* 1.11 - 1.52* 1.15 - 1.80* 1.12 - 1.64*
0.97 1.15 1.65 1.04
0.66 - 1.44 0.97 - 1.35 1.22 - 2.22* 0.75 - 1.44
1.89 1.13 2.08 1.54
1.06 - 3.35* 0.81 - 1.58 1.29 - 3.34* 0.98 - 2.42
1.39
1.23 - 1.56*
1.21
1.03 - 1.42*
1.51
1.06 - 2.16*
1.38 1.80 2.54
0.79 - 2.40 1.21 - 2.68* 2.08 - 3.11*
1.63 1.83 1.91
0.91 - 2.90 1.17 - 2.84* 1.39 - 2.61*
1.97 1.83 2.11
0.78 - 5.01 1.15 - 2.93* 1.38 - 3.23*
2.09
1.75 - 2.50*
1.83
1.46 - 2.29*
2.17
1.60 - 2.94*
1.70 3.46 1.92
1.43 - 2.01* 2.75 - 4.36* 1.54 - 2.40*
1.92 4.29 2.98
1.48 - 2.50* 3.38 - 5.45* 2.14 - 4.14*
1.47 3.90 2.04
0.98 - 2.21 2.74 - 5.54* 1.39 - 3.00*
2.21
1.88 - 2.60*
3.62
3.04 - 4.33*
2.89
2.02 - 4.13*
2.01
1.35 - 2.98*
1.83
0.95 - 3.53
2.20
1.16 - 4.16*
AC C
Model II
M AN U
SC
RI PT
Drug Use Among Those Having Opportunity aOR 95% CIa 1.72 1.49 - 1.98* 1.71 1.37 - 2.14* 1.64 1.23 - 2.18*
TE D
Any disorder MDD/Dys BIP I/II Any mood disorder (MDD/Dys, BIP) AGP SP SO SA Any phobia disorder (AGP, SO, SP, SAD) GAD PAN PTSD Any anxiety disorder (GAD, PAN, PTSD) ADHD CD ODD Any behavior disorder (ADHD, CD, ODD) Any eating disorder Other conditions: Weekly smoking Regular alcohol use
Opportunity to Use Drugs Among NonUsers aOR 95% CIa 1.46 1.29 - 1.65* 1.95 1.72 - 2.22* 1.43 0.90 - 2.28
9.06 4.82
6.86 - 11.96* 3.97 - 5.84*
7.54 4.01
6.32 - 8.99* 3.34 - 4.81*
4.18 3.73
3.17 - 5.51* 2.89 - 4.81*
1.35 1.10
1.16 - 1.56* 0.74 - 1.64
1.20 1.06
0.96 - 1.50 0.79 - 1.43
1.12 1.92
0.85 - 1.48 1.15 - 3.21*
1.30
1.13 - 1.49*
1.17
0.95 - 1.45
1.39
1.12 - 1.73*
1.11 1.16 1.11 1.13
0.81 - 1.52 0.97 - 1.38 0.85 - 1.44 0.92 - 1.40
0.82 1.00 1.24 0.81
0.55 - 1.23 0.81 - 1.24 0.89 - 1.73 0.56 - 1.17
1.48 0.97 1.87 1.13
0.78 - 2.79 0.73 - 1.29 1.35 - 2.60* 0.69 - 1.84
1.20
1.04 - 1.39*
1.00
0.82 - 1.22
1.23
0.88 - 1.71
1.06 1.42 1.91
0.61 - 1.83 1.01 - 2.00* 1.47 - 2.48*
1.13 1.45 1.25
0.57 - 2.22 0.89 - 2.38 0.84 - 1.86
1.16 1.40 1.27
0.32 - 4.18 0.87 - 2.27 0.85 - 1.90
1.64
1.35 - 1.99*
1.28
0.99 - 1.65
1.41
1.05 - 1.88*
1.41 2.43 1.39
1.13 - 1.76* 1.91 - 3.08* 1.12 - 1.73*
1.65 3.24 2.21
1.29 - 2.12* 2.56 - 4.10* 1.65 - 2.97*
1.13 2.52 1.50
0.78 - 1.64 1.84 - 3.46* 1.16 - 1.95*
1.66
1.39 - 1.98*
2.82
2.38 - 3.32*
1.85
1.34 - 2.54*
1.39
0.83 - 2.34
1.44
0.88 - 2.38
1.59
0.87 - 2.93
EP
Model I
Mental Disorder
22
ACCEPTED MANUSCRIPT Other conditions: Weekly smoking Regular alcohol use
6.64 3.69
4.77 - 9.24* 3.05 - 4.46*
5.46 2.97
4.44 - 6.71* 2.43 - 3.62*
2.83 2.67
2.16 - 3.72* 2.08 - 3.44*
AC C
EP
TE D
M AN U
SC
RI PT
Note: ADHD = attention-deficit/hyperactivity disorder; AGP = agoraphobia; BIP = bipolar disorder; CD = conduct disorder; Dys = dysthymia; GAD = general anxiety disorder; MDD = major depressive disorder; ODD = oppositional defiant disorder; PAN = panic disorder; PTSD = posttraumatic stress disorder; SAD = separation anxiety disorder; SO = social phobia; SP = specific phobia. a Model I adjusted for age, sex, race/ethnicity; Model II additionally adjusted for any mood disorder, phobia, anxiety disorder, behavior disorder, eating disorder, weekly smoking, and regular alcohol use (when a mental disorder is the covariate of interest, the specific analysis was not adjusted for this particular mental disorder class, but for all other classes of disorders). *p < .05
23