Psychiatric comorbidity among first-time and repeat DUI offenders

Accepted Manuscript Psychiatric comorbidity among first-time and repeat DUI offenders

Layne M. Keating, Sarah E. Nelson, Rhiannon Wiley, Howard J. Shaffer PII: DOI: Reference:

S0306-4603(18)31443-6 https://doi.org/10.1016/j.addbeh.2019.03.018 AB 5941

To appear in:

Addictive Behaviors

Received date: Revised date: Accepted date:

13 December 2018 4 March 2019 31 March 2019

Please cite this article as: L.M. Keating, S.E. Nelson, R. Wiley, et al., Psychiatric comorbidity among first-time and repeat DUI offenders, Addictive Behaviors, https://doi.org/10.1016/j.addbeh.2019.03.018

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ACCEPTED MANUSCRIPT Running head: FIRST-TIME AND REPEAT DUI OFFENDERS

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Psychiatric Comorbidity among First-Time and Repeat DUI Offenders

Division on Addiction, Cambridge Health Alliance

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Layne M. Keatinga, Sarah E. Nelsona,b, Rhiannon Wileya, Howard J. Shaffera,b

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Harvard Medical School

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Correspondence concerning this article should be addressed to Dr. Sarah Nelson, Division on Addiction, 101 Station Landing, Suite 2100, Medford, MA 02155. Email:

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[email protected]

Abstract Driving under the influence of alcohol or other substances is a serious public health concern. Previous research has shown that psychiatric comorbidity is more prevalent for repeat offenders

ACCEPTED MANUSCRIPT than the general population, and that first-time offenders exhibit elevated rates of psychiatric comorbidity, but few studies have directly compared first-time and repeat DUI offenders. The current study compares psychiatric comorbidity among repeat and first-time DUI offenders. Firsttime and repeat DUI offenders completed the screener module of the Computerized Assessment

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and Referral System (CARS), adapted from the Composite International Diagnostic Interview

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(CIDI: Kessler & Ustun, 2004), to measure potential psychiatric comorbidity. For 16 of 19

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psychiatric disorders, repeat DUI offenders were more likely to screen positive during their lifetime compared with first-time DUI offenders. Similarly, repeat DUI offenders were more likely

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to screen positive during the past year for 11 of 16 assessed psychiatric disorders. Overall, repeat

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DUI offenders screened positive for an average of 6.3 disorders during their lifetime, compared to first-time offenders who screened positive for an average of 3.7 disorders. Repeat DUI offenders

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also screened positive for more past-year disorders (M=3.3) than first-time offenders (M=1.9).

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Compared to first-time offenders, repeat DUI offenders evidence more severe and pervasive psychiatric comorbidity. Further research is necessary to determine whether psychiatric

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comorbidity among first-time offenders directly predicts re-offense. If so, screening for mental

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health issues among first-offenders could provide valuable information about how best to allocate

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resources for these offenders.

Keywords: mental health; comorbidity; alcohol; impaired driving; driving under the influence

Psychiatric Comorbidity among First-Time and Repeat DUI Offenders 1. Introduction

ACCEPTED MANUSCRIPT Driving under the influence of alcohol or other psychoactive substances is a serious public health concern. During 2015, NHTSA reported 10,265 fatalities in alcohol-impaired-driving crashes (NHTSA, 2016). In addition to preventable mortality, DUIs are extremely expensive. Alcohol-related motor vehicle accidents cost the country $44 billion in medical expenses, lost

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productivity, damaged property, and more in 2010 (NHTSA, 2016). Recidivism also is high. About

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25% of individuals arrested and 30% of individuals convicted for DUI have a prior DUI arrest

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(Warren-Kigenyi & Coleman, 2014). According to the National Transportation Safety Board (2000), “hardcore driving drinkers,” which include repeat DUI offenders and offenders with a

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BAC above 0.15, contributed to 40% of alcohol-related motor vehicle accident (MVA) fatalities

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resulting in an economic cost of $5.3 billion in 1998 alone.

Previous research has explored many characteristics of DUI offender populations. For

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example, drivers who self-reported DUI behavior in the National Household Survey on Drug

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Abuse were more likely to be male than female, and more likely to be white, Native American, or mixed race than other races (Caetano & McGrath, 2005). Additionally, in this sample, individuals

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who reported DUI behavior were more likely to suffer from alcohol abuse or dependence, tended

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to be younger, were less likely to be married, and were more likely to have a college education than those who did not report DUI behavior. Most research on DUI populations focuses

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specifically on first-time or repeat DUI offenders (i.e., those arrested for DUI). First-time offenders are a diverse population, even in relation to DUI behavior. A first-time DUI offender might have driven under the influence once, a few times, or hundreds of times. Estimates suggest that only 1% or fewer instances of impaired driving result in arrest (Centers for Disease Control, 2006), so it is likely that the majority of first-time offenders are not first-time impaired drivers. Despite this, some research does show distinct differences between first-time and repeat DUI offenders.

ACCEPTED MANUSCRIPT Both first-time and repeat DUI offenders are predominantly young and male. Studies show that first-time offenders are more likely to be under 40 than over 40, and risk for becoming a repeat DUI offender decreases with age (Caetano & McGrath, 2005; Caldwell-Aden, Kaczowka, & Balis, 2009; Yu & Williford, 1995), though there is some evidence that repeat DUI offenders involved

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in crashes are most likely to be between ages 35-44 (Fu, 2008). Repeat offenders are typically less

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educated than first-time offenders (C'de Baca, Miller, & Lapham, 2001; Fu, 2008) and even more

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likely to be male (Barta, Fisher, & Hynes, 2017; Vaucher et al., 2016). While both first-time and repeat DUI offenders start drinking regularly earlier in their lives and drink more than non-

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offenders, the age of onset of regular drinking is correlated to the number of DUI arrests, and

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repeat DUI offenders exhibit higher levels of alcohol consumption and higher levels of blood alcohol concentration (BAC) upon arrest than first-time offenders (McCutcheon et al., 2009;

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McMillen, Adams, Wells-Parker, Pang, & Anderson, 1992; McMillen, Pang, Wells-Parker, &

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Anderson, 1991)

One domain consistently associated with DUI offense and re-offense is mental health.

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Many studies report elevated rates of not only alcohol and substance use disorders, but also other

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psychiatric disorders among DUI offender populations, particularly repeat offender populations (Freeman, Maxwell, & Davey, 2011; Hubicka, Kallmen, Hiltunen, & Bergman, 2010; Lapham,

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Baca, McMillan, & Lapidus, 2006; Lapham et al., 2001; McCutcheon et al., 2009; Shaffer et al., 2007). In our previous work, we observed that repeat DUI offenders had significantly higher rates of alcohol and drug use disorders, conduct disorder, post-traumatic stress disorder (PTSD), bipolar disorder, and generalized anxiety disorder (GAD), compared to the general population, and were more likely to have multiple comorbid disorders (Albanese, Nelson, Peller, & Shaffer, 2010; Peller, Najavits, Nelson, LaBrie, & Shaffer, 2010; Shaffer et al., 2007). This psychiatric

ACCEPTED MANUSCRIPT comorbidity is associated with both individual and public health consequences. Repeat DUI offenders with a history of comorbid psychiatric disorders in addition to alcohol or drug use disorder appear to be more likely to re-offend criminally than other repeat DUI offenders (Nelson, Belkin, LaPlante, Bosworth, & Shaffer, 2015).

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One question raised by this research is whether this association between psychiatric

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disorders and DUI behavior is limited primarily to repeat DUI offender populations, or whether it

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also might be a risk factor for first-time DUI offense. This question is important for two reasons. First, understanding the nature of the relationship between DUI behavior and mental health is

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necessary to determine whether and how psychiatric issues directly influence DUI. Second,

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understanding the distribution of psychiatric disorders among first-time and repeat DUI offenders allows for better allocation of screening, assessment, and treatment resources within DUI treatment

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programs.

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Theoretically, a causal relationship between mental health issues and continued DUI behavior, mediated through alcohol or substance use, fits within our understanding of addiction.

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The vast majority of repeat DUI offenders qualify for a substance use disorder diagnosis (Shaffer

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et al., 2007). A hallmark characteristic of addiction is continued engagement despite negative consequences (Shaffer, LaPlante, & Nelson, 2012), of which DUI arrest certainly counts as one.

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According to the syndrome model of addiction, a key element influencing the development and persistence of addiction is the presence of individual biopsychosocial vulnerabilities that interact with distal and proximal environmental factors. In the case of DUI offenders, if underlying mental health vulnerabilities remain unaddressed, proximal triggers, such as stress or relationship problems, can lead to maladaptive coping, relapse, and recidivism (Shaffer et al., 2004; Shaffer et al., 2012).

ACCEPTED MANUSCRIPT In terms of the distribution of psychiatric disorders among first-time and repeat DUI offenders, there is limited research available that examines whether first-time DUI offenders exhibit the same elevated psychiatric comorbidity that repeat offenders do. Some research shows an association between DUI and mental health problems, particularly alcohol and substance use

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disorders, within first-time DUI offender populations (Holt, O'Malley, Rounsaville, & Ball, 2009;

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Lapham, Stout, Laxton, & Skipper, 2011; Palmer, Ball, Rounsaville, & O'Malley, 2007). Few

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studies, however, have compared first-time and repeat DUI offender populations directly on mental health characteristics. McMillen and his colleagues (1992) compared first-time DUI

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offenders to those with multiple DUI arrests using personality inventories and Minnesota

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Multiphasic Personality Inventory (MMPI) scales for mania, depression, and psychopathic deviance. Individuals with multiple DUI arrests evidenced higher depression and mania scores, as

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well as higher scores on scales measuring sensation-seeking, hostility, and poor emotional

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adjustment than first-time offenders. However, a study conducted by Cavaiola and colleagues (2003), using the same MMPI scales, reported no differences between first-time and repeat DUI

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offenders on depression, mania, or psychopathic deviance. More recently, Dickson and her

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colleagues conducted interviews with first-time and repeat DUI offenders from rural Appalachia (Dickson, Wasarhaley, & Webster, 2013). They did not observe statistically significant differences

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in self-reported periods of depression, anxiety, tension, or trouble remembering or concentrating between these two samples. The only study of which we are aware to directly compare fist-time and repeat DUI offenders on DSM psychiatric disorder diagnoses reported higher rates of mood disorders (i.e., depressive and bipolar disorders) among repeat DUI offenders, but no differences between the two offender groups on anxiety disorders (Freeman et al., 2011). Thus, the extant

ACCEPTED MANUSCRIPT literature is mixed as to whether first-time and repeat DUI offenders differ fundamentally in their mental health profiles. There is a longstanding debate about what DUI sentencing and treatment should look like for first-time and repeat DUI offenders (e.g., National Center for DWI Courts, 2009; National

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Highway Traffic Safety Administration, 2005). Responses to DUI vary greatly from state to state,

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but most have historically built recidivism prevention around driver education and addressing

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alcohol use disorders (Nelson & Tao, 2012). In addition, sentences and resources are often allocated differently across first-time, repeat, and “hardcore” DUI offenders (National Center for

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DWI Courts, 2009; National Highway Traffic Safety Administration, 2005). Though this is

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logically based on risks and needs, the evidence base upon which these policies are built is limited, particularly in relation to mental health, as described earlier. For example, the National Center for

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DWI Courts has stated that DWI courts are specifically designed for hardcore DWI offenders

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(National Center for DWI Courts, 2009) and that, in most cases, enrolling first-time offenders in DWI court would be an unnecessary expense because many of them will not go on to re-offend.

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If psychiatric conditions beyond substance use disorders influence DUI behavior, the

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deterrence-based and psychoeducational programs that are most common as part of DUI sentencing are likely insufficient to address the root cause of DUI behavior and recidivism.

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Whether these conditions are present among first-time and repeat offenders has direct bearing on how any additional treatment sentencing options resources are allocated. Psychiatric comorbidity has already been indicated as a potentially defining feature of repeat DUI offenders. Determining psychiatric comorbidity among first time offenders, in addition to directly comparing first-time and repeat offender populations, will begin to address the role mental health issues play in both

ACCEPTED MANUSCRIPT initial and re-offense and inform the allocation of resources and interventions for these populations. 1.1. Current Study The current study compares psychiatric comorbidity among first-time and repeat DUI

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offenders. This is one of the first studies to directly compare the psychiatric comorbidity of first-

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time and repeat DUI offenders. Though the study conducted by Freeman and colleagues (2011)

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included DSM diagnoses, they derived information only from a subset of clients who completed intakes at programs within which a clinician collected diagnostic information, and there was no

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standardized data collection protocol across programs. In the current study, we implemented a

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newly developed clinical tool, the Computerized Assessment and Referral System (CARS), at two separate DUI programs: one specifically for repeat DUI offenders and another specifically for first-

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time DUI offenders in the state of Massachusetts. CARS is an adaptation of the pre-existing and

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validated mental health assessment, the Composite International Diagnostic Instrument (CIDI: Kessler & Ustun, 2004). For this study, we utilized the screener module of CARS, which screens

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for risk for 19 different DSM-IV Axis I disorders. As part of a larger randomized trial, participants

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in this study completed the CARS screener as part of their intake to the DUI programs they attended. We hypothesized that repeat DUI offenders would exhibit higher rates of both lifetime

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and past year positive screens for mental health disorders compared to first-time DUI offenders. 2. Methods

2.1. Participants The sample for this study consists of DUI offenders recruited from two court-mandated DUI programs in Massachusetts. First-time DUI offenders in Massachusetts can enroll in a Driver Alcohol Education (DAE) program to reduce the length of license suspension (General Laws of Massachusetts, 2018). Behavioral Health Network (BHN), a behavioral health agency in western

ACCEPTED MANUSCRIPT Massachusetts (western MA), offers a DAE program that serves 400-450 offenders a year across three separate locations – one urban, and two rural. The Middlesex Driving Under the Influence of Liquor Program (MDUIL) is a two-week residential program for individuals convicted of two DUI offenses in Massachusetts. This program is an alternative to incarceration and is the only

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program of its kind in the state. It serves approximately 1,200 – 1,500 offenders a year.

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During the 6-month course of the study, we approached all new DAE program enrollees at

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the three BHN locations. As Figure 1 shows, of the 229 scheduled for an intake appointment during this time, 163 first-time DUI offenders (71.2%) agreed to participate in the study. Two of those

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participants decided not to participate after going through the consent procedure. We also invited

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repeat DUI offenders from 13 two-week cohorts at MDUIL to participate. As Figure 1 shows, we recruited 375 repeat DUI offenders from MDUIL, or 51.4% of their total admissions (n = 729) in

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that time period. Thirty (8.0%) of those participants dropped out of the study before completing

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any assessments, largely due to early discharge from the MDUIL program. A subset of those recruited to the study completed the Computerized Assessment and Referral System (CARS); the

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other participants were assigned to an intake as usual condition. The current manuscript reports

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about the 122 first-time offenders and 261 repeat offenders (N = 383) who completed the screener module of the CARS assessment.

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2.2. Procedure

For first-time DUI offender participants, BHN staff members introduced the study to each client and conducted oral informed consent procedures during a phone call to schedule that client’s intake interview for the DAE program. At their DAE intake interviews, DUI offenders who wished to participate in the study signed the informed consent form and, if assigned to a condition utilizing the CARS assessment, completed the CARS assessment either as a computer-guided interview

ACCEPTED MANUSCRIPT with their intake coordinator or as a self-administered computerized interview. There were very few differences between results from those two conditions, so they are combined for purposes of this paper. At the end of their intake interview, first-time DUI offenders completed an additional packet of surveys. Upon completion of these surveys, participants received a $20 gift card for their

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participation.

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For repeat DUI offender participants, researchers introduced the study to each cohort of

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clients during their second day at the MDUIL program and conducted informed consent procedures individually with clients. DUI offenders who agreed to participate and were assigned to a condition

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utilizing the CARS assessment completed the CARS assessment either as a computer-guided

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interview with their counselor or as a self-administered computerized interview. At the end of their two-week program, participants completed the same additional packet of surveys as first-time DUI

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offender participants, and received a $20 gift card for their participation. This study received

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approval from the Cambridge Health Alliance Institutional Review Board. 2.3. Measures

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As discussed above, the Computerized Assessment and Referral System (CARS) was the

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primary measure employed in this study. CARS is a computerized diagnostic interview that is directly adapted from the Composite International Diagnostic Interview (CIDI: Kessler & Ustun,

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2004)), with assistance from the CIDI developers. The CIDI has been validated internationally (Kessler et al., 2004; Wittchen, 1994). CARS maintains the CIDI’s question content for criteria related to DSM-IV Axis I disorders, but expands the detailed assessment of lifetime history of disorders to include the same level of detail for past year disorder diagnoses. In addition, CARS includes a screener module that asks about more criteria for each assessed disorder than does the CIDI screener, improving the CARS screener’s specificity. For this study, we include data from

ACCEPTED MANUSCRIPT the CARS screener, which was completed by all participants assigned to have a CARS assessment. The CARS screener includes questions about criteria for 19 different DSM-IV disorders: panic disorder, generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, mania, major depressive disorder, dysthymia, tobacco use disorder, alcohol use disorder, drug use

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disorder, gambling disorder, binge eating disorder, anorexia, intermittent explosive disorder,

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obsessive-compulsive disorder, psychosis, attention deficit / hyperactivity disorder, oppositional

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defiant disorder, and conduct disorder, as well as a screen for suicidality. Although a positive screen indicates risk for a disorder, it does not constitute an actual diagnosis. Table 1 includes

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details about symptom and criteria endorsement required to achieve a positive CARS screen for

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each disorder. For most disorders, the CARS screener asks questions in both a lifetime and past year timeframe; the exceptions to this include attention deficit / hyperactivity disorder,

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oppositional defiant disorder, and conduct disorder, because these questions assess childhood

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experiences.

In addition, we included several variables from the self-administered version of the

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Addiction Severity Index (Rosen, Henson, Finney, & Moos, 2000), which participants completed

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as part of the battery of surveys they filled out. These questions included measures of past 30-day experience of mental health symptoms and past 30-day alcohol and other drug use. Participants in

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the repeat DUI offender residential program answered these questions for the 30 days prior to their entry into the program. 2.4. Data analyses We applied algorithms to the CARS screener data to create variables indicating whether participants screened positive for each disorder during their lifetime and during the past 12 months. We used SPSS to conduct chi square analyses to determine if the numbers of positive screens for

ACCEPTED MANUSCRIPT each disorder differed between first-time and repeat DUI offender participants. We also calculated the average number of lifetime and past year positive screens for repeat and first time DUI offenders and compared these values using ANOVAs. Next, we conducted two logistic regressions to identify the mental health screens that

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predicted repeat DUI offender status. For each logistic regression, we first entered the following

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control variables: gender, age, race, ethnicity, and condition (i.e., self-administered screener vs.

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counselor-administered screener). In the first logistic regression, we then entered each of the 11 lifetime disorder screening variables that differed between first-time offenders and repeat DUI

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offenders at a p < .01 level according to our chi square analyses. We used a threshold of p < .01 to

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help reduce our data for the models. In the second logistic regression, after the control variables, we entered each of the 12 past year disorder screening variables that differed between first-time

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and repeat offenders – again at a p < .01 level according to our chi square analyses. As an

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exploratory measure, we also conducted a logistic regression predicting repeat DUI offender status from the control variables and variables measuring the number of positive lifetime disorder screens

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and number of positive past year disorder screens participants received.

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To ensure that our findings did not reflect geographic differences between the programs serving first-time and repeat offenders (e.g., the more rural setting of western MA, compared to

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other parts of the state), we repeated the above analyses including all of the first-time offenders and only the subset of repeat DUI offenders whose residences were in western MA, where the first-time offenders resided. This subsample included 43 of the 261 repeat offenders. 3. Results 3.1. Demographics

ACCEPTED MANUSCRIPT Table 2 displays sample demographics. Both first-time offender and repeat offender populations were primarily male and non-Hispanic white. The sample demographics did not differ significantly by offender status. 3.2. Past year and lifetime positive psychiatric disorder screens

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There was substantial psychiatric comorbidity among both first time and repeat DUI

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offender samples. As displayed in Table 3, repeat offenders were more likely to screen positively

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for many lifetime and past year psychiatric disorders compared to first time offenders, as hypothesized. The only lifetime disorder screens for which first-time and repeat offenders had

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similar rates were major depressive disorder and eating disorders; for the other 16 disorders, repeat

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offenders evidenced higher rates, X2 (1, N=383) = 4.19 – 23.69, p < .05. Past year positive screen rates differed for all disorders except alcohol use disorder, drug use disorder, gambling disorder,

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and eating disorders, X2 (1, N=383) = 4.2 – 16.6, p < .05. Differences between first-time and repeat

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DUI offenders appeared greatest – both lifetime and past-year – for panic disorder, generalized anxiety disorder, post-traumatic stress disorder, intermittent explosive disorder, and obsessive-

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compulsive disorder, as well as childhood onset disorders. Overall, repeat DUI offenders screened

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positive for an average of 6.25 disorders (SD=3.97) in their lifetime and 3.31 (SD=2.76) in the past year, significantly higher numbers than first-time DUI offenders, who screened positive for

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an average of 3.65 lifetime disorders (SD=3.18) and 1.89 past year disorders (SD=2.01), F(1,381) = 40.31, p < .001 for lifetime screens and F(1,381) = 26.00, p < .001 for past year screens. When we considered only the subset of repeat DUI offenders from a similar geographic region to the first offender population, many of these differences disappeared, primarily due to a lack of power (i.e., the difference remained similar but the smaller n reduced the statistical significance of that difference). Lifetime alcohol use disorder, post-traumatic stress disorder, mania, attention deficit

ACCEPTED MANUSCRIPT / hyperactivity disorder, and conduct disorder positive screen rates remained significantly elevated in the repeat DUI offender subsample, as did past year positive screen rates for generalized anxiety disorder and intermittent explosive disorder. In addition, the subsample of repeat DUI offender still had elevated average numbers of

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positive screens (5.65 lifetime [SD=3.57] and 2.93 past year [SD=2.60]) compared to first-time

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offenders (3.65 lifetime [SD=3.18] and 1.19 past year [SD=2.01]), F(1,163) = 11.84, p < .01 for

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lifetime screens and F(1,163) = 7.30, p < .01 for past year screens. 3.3. Past 30-Day Experiences

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Investigation of past 30-day experience of symptoms, presented in Table 4, indicated that

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first-time and repeat DUI offenders did not differ significantly in their experience of mental health symptoms and substance use problems in the month prior to program intake. The only significant

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difference was in trouble controlling violent behavior in the past month, reported by 7.2% of repeat

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DUI offenders, but only 1.7% of first-time DUI offenders. In addition, repeat DUI offenders reported drinking on significantly fewer days in the past month than first-time offenders. No

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differences were found in past-30-day symptoms or behavior when only the subset of repeat DUI

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offenders from a similar geographic region to the first offender population were considered. 3.4. Predicting Repeat DUI Offender Status

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As we described previously in Section 2.4, we conducted two logistic regressions predicting repeat DUI offender status from lifetime and past-year positive disorder screens, respectively. Both logistic regressions also included a set of control variables. Table 5 summarizes the results of those regressions. Ethnicity was the only control variable that contributed significantly to both final models – consistent with the descriptive statistics presented in Table 2, repeat DUI offenders were more likely to be Hispanic. For both models, the addition of mental

ACCEPTED MANUSCRIPT health variables contributed significantly to the model, as indicated by the significant Step χ2s. In the model with lifetime psychiatric disorder screens, the addition of those variables improved the model’s classification accuracy from 68.2% percent correct (i.e., the model with control variables) to 73.8% correct, and improved the area under the receiver operating characteristic curve (AUC)

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for the model from 0.62 to 0.75. In the model with past year psychiatric disorder screens, the

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addition of those variables improved the model’s classification accuracy from 68.2% correct to

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70.1% correct, and improved the AUC for the model from 0.62 to 0.71. Specific positive screens

generalized anxiety and tobacco use disorders.

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that contributed significantly to the models included lifetime alcohol use disorder and past year

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Exploratory regression models predicting offender status from only (1) control variables and (2) the number of positive disorder screens offenders received performed almost as well as the

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models described in the previous paragraph. Adding number of lifetime disorder screens to a model

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with control variables improved the model significantly (Step χ 2 = 44.55, p < .001; Odds Ratio = 1.25 [1.16, 1.35]), improving classification accuracy from 68.2% correct to 72.7% correct, and

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improving the model’s AUC from 0.62 to 0.73. Adding number of past year disorder screens to a

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model with control variables improved the model significantly (Step χ2 = 30.44, p < .001; Odds Ratio = 1.32 [1.18, 1.48]), improving classification accuracy from 68.2% correct to 72.2% correct,

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and improving the model’s AUC from 0.62 to 0.70. In a model that included counts of both lifetime and past year disorder screens, as well as control variables, lifetime counts contributed significantly to the model (Odds Ratio = 1.26 [1.11, 1.43]), but past year counts did not (Odds Ratio = 0.99 [0.81, 1.20]). When we considered only the subset of repeat DUI offenders from a similar geographic region to the first offender population, the addition of mental health variables continued to

ACCEPTED MANUSCRIPT contribute significantly to the model (lifetime model Step χ2 = 22.38, p < .05; past year model Step χ2 = 9.68, p < .05). The addition of lifetime psychiatric disorder screens improved the model’s classification accuracy from 74.5% percent correct (i.e., the model with control variables) to 78.8% correct, and the model’s AUC from 0.64 to 0.76. For the model with past year psychiatric disorder

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screens, the addition of those variables improved the model’s classification accuracy from 74.5%

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correct to 77.0% correct, and the model’s AUC from 0.64 to 0.70. The only positive screen that

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continued to contribute significantly to the model was past year generalized anxiety. In both models, ethnicity continued to be the only control variable that contributed significantly; again,

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repeat DUI offenders were more likely to be Hispanic than first-time DUI offenders. The

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exploratory models exhibited the same trends as in the full sample when repeated with the repeat offender subset: adding number of lifetime disorder screens to a model with control variables

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improved the model significantly (Step χ2 = 10.40, p < .01; Odds Ratio = 1.19 [1.07, 1.32]), as did

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adding number of past year disorder screens (Step χ2 = 7.91, p < .01; Odds Ratio = 1.25 [1.07, 1.46]). Adding number of lifetime disorder screens improved the model’s AUC from 0.64 to 0.71,

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and adding number of past year disorder screens improved the model’s AUC from 0.64 to 0.70.

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However, classification accuracy did not increase meaningfully, and in a model with both lifetime and past year disorder counts, neither of these counts contributed significantly, though their

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addition did improve the model overall (Step χ2 = 10.48, p < .01). 4. Discussion

We observed higher levels of psychiatric comorbidity among repeat DUI offenders compared to first-time offenders in our sample. Repeat DUI offenders exhibited particularly high rates of positive screens for anxiety disorders, post-traumatic stress disorder, intermittent explosive disorder, obsessive-compulsive disorder, attention deficit / hyperactivity disorder, oppositional

ACCEPTED MANUSCRIPT defiant disorder, and conduct disorder compared to first-time offenders. This supports previous research that finds high rates of psychiatric comorbidity among repeat DUI offenders (Shaffer et al., 2007) and higher rate of criminal re-offense among repeat DUI offenders with psychiatric comorbidity (Nelson et al., 2015). However, it is important to note that not only did the majority

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of first-time offenders screen positive for past year alcohol use disorder, but more than a quarter

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screened positive for generalized anxiety disorder during their lifetime, and almost a third screened

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positive for panic disorder in their lifetime. These findings suggest that a substantial proportion of these offenders experienced meaningful anxiety-related issues.

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The utility of psychiatric comorbidity as a predictor of repeat DUI offense appears to vary

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by timing of experience. Past 30-day experiences of psychiatric disorders do not distinguish between first-time and repeat DUI offenders; the exception to this finding is that difficulty

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controlling violent behavior is elevated among repeat offenders. This finding might indicate that

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tendencies towards impulsivity and aggression among repeat offenders are more enduring characteristics for this population compared with other experiences of psychiatric comorbidity,

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which might wax and wane. In general, past 30-day experiences of psychiatric disorders might be

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more reflective of current psychological states rather than enduring traits. All participants in our sample had experienced a relatively recent DUI arrest and were, at the time of study, experiencing

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the consequences of that arrest. This circumstance could have influenced the emotional states of both groups of participants, resulting in a common experience of recent psychological symptoms. Perhaps counter-intuitively, though lifetime rates of alcohol use disorder are higher among repeat DUI offenders, past year and past 30-day experiences of alcohol use disorder do not differ between first-time and repeat offenders. However, the legal consequences of repeat DUI might help to explain this finding. Many repeat DUI offenders across the country are enrolled in programs

ACCEPTED MANUSCRIPT or have sentencing conditions that disallow or discourage drinking. This would account for the large difference between the lifetime and past year alcohol use disorder rates of repeat offenders in our sample, as well as the lower frequency of drinking in the past 30 days compared to firsttime offenders.

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Overall, except for anxiety-related disorders, patterns of lifetime comorbidity appear to be

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better predictors of repeat DUI offense than past year experiences. This indicates that repeat DUI

CR

offenders might possess stable, trait-like psychological profiles that distinguish them from firsttime DUI offenders. If this is the case, then it might be possible to identify a subset of individuals

US

who are at higher risk for becoming repeat offenders among first-time DUI offenders by examining

AN

these lifetime histories, allowing better resource allocation for intervention programs. Anxiety-related problems, although prevalent among both first-time and repeat DUI

M

offenders, appear to be particularly persistent among repeat offenders – repeat DUI offenders

ED

experience high rates of positive screens for anxiety-related disorders within both the lifetime and past year timeframe. These findings contrast with results from previous comparisons of first-time

PT

and repeat DUI offenders that did not observe anxiety level differences (Dickson et al., 2013;

CE

Freeman et al., 2011). Recent experiences of anxiety might act as a proximal trigger for DUI behaviors. For example, there is evidence that drinking in response to negative emotions mediates

AC

the relationship between social anxiety and heavy situational drinking (Terlecki & Buckner, 2015). As noted earlier, the syndrome model of addiction (Shaffer et al., 2004; Shaffer et al., 2012) suggests that underlying mental health vulnerabilities (e.g., anxiety disorders) might interact with proximal triggers (e.g., stressful life events) to exacerbate reactions to those triggers (e.g., symptoms of anxiety) and result in relapse and recidivism.

ACCEPTED MANUSCRIPT Lifetime experiences of depression and suicidality did not distinguish repeat DUI offenders from first-time offenders, in contrast to the findings of both McMillen et al. (1992) and Freeman et al. (2011), but consistent with the findings of Cavaiola et al. (2003) and Dickson et al. (2013). This result could reflect a tendency towards externalizing rather internalizing symptoms among

T

repeat DUI offenders in our sample. To illustrate, as Table 3 summarized, we observed

IP

significantly higher rates of lifetime attention deficit / hyperactivity disorder, oppositional defiant

CR

disorder, intermittent explosive disorder, conduct disorder, and addictive disorders (including gambling, alcohol, tobacco, and other substances) among our repeat offender sample compared to

US

first-time offenders.

AN

Both lifetime and past year experiences of post-traumatic stress disorder were uniquely elevated for repeat DUI offenders. DUI offenders with post-traumatic stress disorder have been

M

observed to have worse psychiatric comorbidity in general than DUI offenders without post-

ED

traumatic stress disorder (Peller et al., 2010). Given the positive association between the likelihood of DUI re-offense and psychiatric complexity (Nelson et al., 2015), it is unsurprising that repeat

PT

DUI offenders in the present sample experienced elevated rates of post-traumatic stress disorder.

CE

Post-traumatic stress symptoms themselves can be triggers for alcohol use (Coffey et al., 2002; Waldrop, Back, Verduin, & Brady, 2007), indicating a potential causal link between post-traumatic

AC

stress disorder and DUI behavior. Notably, one of our control variables, ethnicity, distinguished first-time and repeat DUI offenders, both for the full sample and for the subsample confined to offenders from western MA. In these samples, repeat DUI offenders were more likely to report Hispanic ethnicity than firsttime offenders. The persistence of this effect after controlling for geographic differences within Massachusetts, is worth further consideration. Some past research supports the idea that Hispanic

ACCEPTED MANUSCRIPT men might be at higher risk for DUI behavior and arrest than other individuals (Caetano & Clark, 2000). However, other work suggests that Hispanic DUI offenders are less likely to report symptoms of psychiatric disorders than other DUI offenders (C'De Baca, Lapham, Skipper, & Hunt, 2004). In our sample, only 4% of first-time offenders and 9% of repeat DUI offenders were

T

Hispanic, so these findings should be interpreted with caution. Further research is needed to

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determine the role ethnicity, as well as corresponding social determinants, plays in DUI recidivism

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across different regions and jurisdictions.

Overall, we observed high levels of psychiatric symptoms among both first-time and repeat

US

DUI offenders within our sample. First-time offenders on average screened positive for more than

AN

three lifetime disorders, and repeat offenders screened positive for more than six. The results of our exploratory model suggest that it is the overall count of psychiatric disorders present that

M

increases risk for repeat DUI behavior, more than the presence of any particular disorder. This

ED

finding highlights the need for adequate mental health treatment for DUI offenders. The association between psychiatric comorbidity and DUI re-offense suggests that treatment-based

PT

policies for repeat DUI offenders might do better to prevent repeat DUI than sanctions alone.

CE

Previous researchers have observed heterogeneity within DUI populations and have suggested matching treatments to individual offenders’ specific needs (Lapham et al., 2001; Nelson, Shoov,

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LaBrie, & Shaffer, 2019).

DUI treatment programs can begin to address the underlying mental health needs of DUI offenders by implementing comprehensive mental health screening that includes disorders beyond substance use, followed by referral to treatment. By establishing comprehensive mental health screening for all first-time DUI offenders, it also might be possible to identify the individuals who are at risk for becoming repeat offenders based on their psychiatric profiles. Screening would allow

ACCEPTED MANUSCRIPT for more effective resource allocation to provide more intensive treatment services for these individuals. This approach attempts to prevent the extreme public health risks related to impaired driving after an individual’s first offense, rather than waiting until they become a repeat DUI offender. DUI programs could also incorporate evidence-based curricula for disorders implicated

T

in risk for repeat offense that can be administered in group settings without a clinician (e.g.,

CR

4.1. Limitations

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Seeking Safety for PTSD and SUD: Najavits, 2002).

A primary limitation of this study was that our samples of first-time and repeat DUI

US

offenders attended different programs in different regions of the state. However, we addressed this

AN

limitation by replicating our analyses with the sub-sample of repeat offenders from western MA, where most of our first-time offenders resided. Because this study utilized a cross-sectional design,

M

we cannot evaluate causal links between psychiatric comorbidity and repeat DUI offense, though

ED

prior work suggests the existence of at least a prospective (i.e., comorbidity preceding and predicting DUI recidivism) if not causal relation (Nelson et al., 2015). We collected data in this

PT

study using solely self-report methods, which might be subject to socially desirable responding

CE

bias by participants (Kazdin, 2003). The differential importance of lifetime versus past year experiences of psychiatric symptoms also might be attributed to statistical power. Past year

AC

experiences are a subset of lifetime experiences; therefore, the chances of an individual experiencing particular symptoms of a mental disorder are necessarily higher for a lifetime scale compared to a past year scale. Further, the current data are based on positive screens for psychiatric disorders rather than comprehensive diagnostic assessments. As a result, the rates of psychiatric comorbidity in our current sample might be inflated. Nevertheless, self-report of lifetime mental health symptoms in cross-sectional research has been found to be prone to underestimation as

ACCEPTED MANUSCRIPT opposed to overestimation (Takayanagi et al., 2014). Our screening measure relied on DSM-IV criteria, rather than DSM-5 criteria, so we might have obtained slightly different rates of positive psychiatric disorder screens compared to those obtained using a DSM-5 based screener; however, we are in the process of updating CARS to DSM-5, and the changes to screening questions based

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on the DSM-5 revisions are minimal.

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4.2. Areas for Future Research

CR

Future lines of DUI inquiry might include comparisons of first and repeat DUI offender samples with general population samples to assess the severity of psychiatric comorbidity among

US

these offender groups compared to non-offenders. We need prospective longitudinal studies in this

AN

field to investigate the temporal order of mental health experiences and DUI behavior. This research is necessary, but not sufficient, to establish whether there is a causal relationship between

M

psychiatric symptoms and DUI behavior. Investigation into the potential mechanisms through

ED

which psychiatric comorbidity might influence DUI could focus on the possible relationship between anxiety disorders and DUI given the persistently elevated experiences of anxiety among

PT

repeat offenders across both lifetime and past year timeframes. The same can be said for the

CE

relationship between DUI and post-traumatic stress disorder. Establishing these links between psychiatric symptoms and DUI behavior would further support the need for treatment-based

AC

responses to DUI behavior and mental health screening when DUI offenders first appear in the court system.

4.3. Conclusions This research identified a number of differences in the experience of mental health issues between first-time and repeat DUI offenders in the Commonwealth of Massachusetts. In particular, we observed elevated persistent experiences of anxiety and post-traumatic stress symptoms among

ACCEPTED MANUSCRIPT repeat DUI offenders. Repeat offenders also experienced significantly higher lifetime rates of positive screens for externalizing disorders compared to first-time offenders. However, a considerable proportion of first-time offenders exhibited positive screens for anxiety disorders, post-traumatic stress disorder, and depressive disorders. High rates of psychiatric comorbidity

T

among DUI offenders beyond substance use disorders point to the need for comprehensive mental

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ED

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AN

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health assessments and the integration of treatment-based approaches to DUI programming.

ACCEPTED MANUSCRIPT Acknowledgements The authors extend special thanks to the staff at Middlesex Driving Under the Influence of Liquor treatment program (MDUIL), and Behavioral Health Network for their collaboration on this project. The authors also thank Alec Conte, Scarvel Harris, Jed Jeng, Kat Belkin, Emily

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Shoov, John Kleschinsky, Debi LaPlante, and Heather Gray for their collaboration on this

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project.

ACCEPTED MANUSCRIPT References

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Albanese, M. J., Nelson, S. E., Peller, A. J., & Shaffer, H. J. (2010). Bipolar disorder as a risk factor for repeat DUI behavior. Journal of Affective Disorders, 121(3), 253-257. doi:S0165-0327(09)00275-4 [pii] 10.1016/j.jad.2009.06.015 Barta, W. D., Fisher, V., & Hynes, P. (2017). Decreased re-conviction rates of DUI offenders with intensive supervision and home confinement. Am J Drug Alcohol Abuse, 43(6), 742746. doi:10.1080/00952990.2016.1237519 C'De Baca, J., Lapham, S. C., Skipper, B. J., & Hunt, W. C. (2004). Psychiatric disorders of convicted DWI offenders: a comparison among Hispanics, American Indians and nonHispanic whites. Journal of Studies on Alcohol, 65(4), 419-427. C'de Baca, J., Miller, W. R., & Lapham, S. C. (2001). A multiple risk factor approach for predicting DWI recidivism. Journal of Substance Abuse Treatment, 21(4), 207-215. Caetano, R., & Clark, C. L. (2000). Hispanics, Blacks and White driving under the influence of alcohol: results from the 1995 National Alcohol Survey. Accid Anal Prev, 32(1), 57-64. Caetano, R., & McGrath, C. (2005). Driving under the influence (DUI) among U.S. ethnic groups. Accid Anal Prev, 37(2), 217-224. doi:10.1016/j.aap.2004.07.004 Caldwell-Aden, L., Kaczowka, M., & Balis, N. (2009). Preventing first-time DWI offenses: First-time DWI offenders in California, New York, and Florida: An analysis of past criminality and associated criminal justice interventions. Retrieved from Washington, DC: Cavaiola, A. A., Strohmetz, D. B., Wolf, J. M., & Lavender, N. J. (2003). Comparison of DWI offenders with non-DWI individuals on the MMPI-2 and the Michigan Alcoholism Screening Test. Addictive Behaviors, 28(5), 971-977. doi:S030646030100291X [pii] Centers for Disease Control. (2006). Alcohol factsheet - General information. Retrieved from http://www.cdc.gov/alcohol/factsheets/general_information.htm Coffey, S. F., Saladin, M. E., Drobes, D. J., T., B. K., Dansky, B. S., & Kilpatrick, D. G. (2002). Trauma and substance cue reactivity in individuals with comorbid posttraumatic stress disorder and cocaine or alcohol dependence. Drug and Alcohol Dependence, 65(2), 115127. Dickson, M. F., Wasarhaley, N. E., & Webster, J. M. (2013). A comparison of first time and repeat rural DUI offenders. J Offender Rehabil, 52(6), 421-437. doi:10.1080/10509674.2013.813616 Freeman, J., Maxwell, J. C., & Davey, J. (2011). Unraveling the complexity of driving while intoxicated: A study into the prevalence of psychiatric and substance abuse comorbidity. Accident Analysis and Prevention, 43(1), 34-39. doi:S0001-4575(10)00168-5 [pii] 10.1016/j.aap.2010.06.004 Fu, H. (2008). Identifying repeat DUI crash factors using state crash records. Accident Analysis and Prevention, 40, 2037-2042. doi:10.1016/j.aap.2008.08.020 General Laws of Massachusetts. (2018). Motor vehicles and aircraft, Part 1, Title XIV, Chapter 90, Section 24. Retrieved from http://www.state.ma.us/legis/laws/mgl/90-24.htm Holt, L. J., O'Malley, S. S., Rounsaville, B. J., & Ball, S. A. (2009). Depressive symptoms, drinking consequences, and motivation to change in first time DWI offenders. The American Journal of Drug and Alcohol Abuse, 35, 117-122.

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Yu, J., & Williford, W. R. (1995). Drunk-driving recidivism: predicting factors from arrest context and case disposition. J Stud Alcohol, 56(1), 60-66.

ACCEPTED MANUSCRIPT Table 1. Criteria Required to Receive a Positive CARS Psychiatric Disorder Screen.

Social Anxiety

CR

Post-Traumatic Stress Disorder

T

Generalized Anxiety Disorder

IP

Panic Disorder

Criteria for a Positive Screen Participant reported having an attack of fear or panic and endorsed 3 or more symptoms of a panic attack (e.g., sweating, feeling dizzy or faint, trembling or shaking, etc.) Participant reported having a time in their life when they worried a lot more about things or were more nervous or anxious than most other people. Additionally, the participant often or sometimes found it difficult to control this anxiety or worry. Participant reported 2 or more symptoms (e.g., sweating, trembling, feeling dizzy, etc.) when in situations where they felt very afraid or shy with people or when they had to do something in front of a group. Participant reported having a traumatic experience which continued to bother them for a period of time and resulting in persistent problems or reactions like upsetting dreams, trouble sleeping or concentrating, or feeling jumpy or easily startled. Participant reported times in their life lasting 4 days or longer where they felt much more excited and full of energy than usual and/or were very irritable or in a bad mood, in addition to experiencing changes in thinking or behaviors at the same time. Participant reported a time lasting 2 weeks or longer when they felt sad or discouraged most of the day every day. Participant reported a year or more in their life when they had several different episodes lasting 3-13 days when they felt sad or discouraged most of the day every day. Participant reported that they seriously thought about committing suicide. Participant reported 1 or more problem related to their tobacco use (e.g., developing a physical tolerance, experiencing withdrawal symptoms, etc.). Participant reported 1 or more problem related to their alcohol use (e.g., experiencing withdrawal symptoms, difficulty stopping or cutting down or their alcohol use, etc.). Participant reported 1 or more problem related to their drug use (e.g., experiencing withdrawal symptoms, difficulty stopping or cutting down or their drug use, etc.). Participant reported 1 or more problem related to their gambling (e.g., experiencing withdrawal symptoms, needing financial help because of gambling, etc.). Participant reported eating binges at least twice a week for several months or longer Participant reported a time in their life where they had a great deal of concern about or strongly feared being too overweight, their self-esteem or confidence depended on the ability to stay thin or lose weight, and their weight was below a minimum threshold. Participant reported having 3 or more attacks of anger where they all of a sudden lost control and broke or smashed something or hit or tried to hurt someone. Participant reported having repeated thoughts, images, impulses, or repeated behaviors they felt driven to do that they paid more attention to than they deserved or that caused them emotional distress. Participant reported seeing a vision that other people could not see or hearing voices that others could not hear, and this happened when the participant was not dreaming, half-asleep, or under the influence of alcohol or other drugs. Participants reported a time before the age of 7 lasting 6 months or longer where they experienced 4 or more symptoms of restless behavior or difficulty concentrating. Participant reported a time during their childhood or adolescence lasting 6 months or longer where they endorsed 3 or more behaviors that got them in trouble with adults (e.g., frequently losing temper, frequently disobeying rules, annoying others on purpose, etc.) Participant reported a time during their childhood or teenage years where they endorsed 2 or more behaviors that adults didn’t want them to do (i.e., shoplifting or stealing, breaking into a car or home, setting fires to cause serious damage, skipping school without permission, etc.).

Mania

Alcohol Use Disorder Drug Use Disorder Gambling Disorder Binge Eating Disorder Anorexia

CE

Intermittent Explosive Disorder

M

Tobacco Use Disorder

ED

Suicidality

PT

Dysthymia

AN

US

Major Depressive Disorder

Psychosis

AC

Obsessive Compulsive Disorder

Attention Deficit / Hyperactivity Disorder Oppositional Defiant Disorder

Conduct Disorder

ACCEPTED MANUSCRIPT Table 2. Sample Demographics.

Marital Status

Past 30-Day Income (among those working)

ED

Past 30-Day Employment

M

AN

Race

T

Ethnicity

IP

Age

Female Male Mean Std. Dev Median Hispanic/Latino Not Hispanic/Latino White Black Asian Pacific Islander Native American Multi-racial Other Never Married Separated Divorced Married Widowed Worked 0 days Worked 1+ days Mean Std. Dev Median

MDUIL: Repeat DUI Offenders N = 261 78 (30.0%) 182 (70.0%) 38.2 11.0 35.0 24 (9.2%) 236 (90.8%) 225 (86.2%) 14 (5.4%) 1 (0.4%) 0 (0%) 1 (0.4%) 2 (0.8%) 18 (6.9%) 150 (57.9%) 17 (6.6%) 47 (18.1%) 41 (15.8%) 4 (1.5%) 85 (35.0%) 158 (65.0%) $4010.88 $11084.81 $1410.00

CR

Gender

US

Demographics

BHN: First-time DUI Offenders N = 122 38 (31.1%) 84 (68.9%) 36.1 13.1 32.5 5 (4.1%) 117 (95.9%) 104 (85.2%) 12 (9.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 2 (1.6%) 77 (63.6%) 8 (6.6%) 14 (11.6%) 19 (15.7%) 3 (2.5%) 34 (29.1%) 83 (70.9%) $2,252.92 $2014.42 $1750.00

Total N = 383 116 (30.4%) 266 (69.6%) 37.5 11.8 35.0 29 (7.6%) 353 (92.4%) 329 (85.9%) 26 (6.8%) 2 (0.5%) 1 (0.3%) 2 (0.5%) 3 (0.8%) 20 (5.2%) 227 (59.7%) 25 (6.6%) 61 (16.1%) 60 (15.8%) 7 (1.8%) 119 (33.1%) 241 (66.9%) $3,399.42 $9058.25 $1500.00

AC

CE

PT

Note. BHN=Behavioral Health Network; MDUIL=Middlesex Driving Under the Influence of Liquor Program.

ACCEPTED MANUSCRIPT Table 3. Positive Psychiatric Disorder Screen Rates for First-Time and Repeat DUI Offenders.

Panic Disorder Social Anxiety Disorder Post-Traumatic Stress Disorder Mania Major Depressive Disorder Dysthymia Suicidality Intermittent Explosive Disorder Obsessive Compulsive Disorder

AC

Anorexia

CE

Binge Eating Disorder

Psychosis

Attention Deficit/ LT 11.5 Hyperactivity Disorder Oppositional Defiant LT 10.7 Disorder Conduct LT 22.1 Disorder LT=Lifetime; PY=Past Year *Significantly different from first-time DUI offenders, p < .05. **Significantly different from first-time DUI offenders, p < .01. ***Significantly different from first-time DUI offenders, p < .001.

Western MA Repeat DUI Offenders (N = 43) % 97.7** 62.8 30.2 9.3 60.5 48.8 4.7 2.3 39.5 30.2** 44.2 23.3 27.9 14.0 34.9** 8.6 27.9** 16.3 23.3 14.0 7.0 9.3 18.6 4.7 23.3 14.0* 14.0 11.6 11.6 11.6* 0.0 0.0 7.0 2.3

T

IP

CR

Generalized Anxiety Disorder

Repeat DUI Offenders (N = 261) % 93.9*** 63.2 36.4*** 14.2 66.3* 56.3*** 6.1* 3.1 41.4** 31.8*** 50.2** 29.1* 31.0* 15.7* 33.7*** 21.8* 23.4** 14.9* 25.7 17.6** 14.9* 9.2* 18.8 8.4* 29.5*** 11.5* 24.1*** 18.0** 11.1 7.7 5.7 4.6 6.5* 3.8*

US

Gambling Disorder

AN

Tobacco Dependence

M

Other Drug Use Disorder

LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY LT PY

PT

Alcohol Use Disorder

ED

Screened Disorder

First-time DUI Offenders (N = 122) % 79.5 62.3 16.4 9.8 54.9 35.2 0.8 0.8 25.4 12.3 32.0 17.2 20.5 6.6 14.8 11.5 9.8 6.6 18.0 5.7 5.7 3.3 11.5 2.5 12.3 4.9 8.2 4.9 5.7 3.3 3.3 1.6 1.6 0.0

29.5***

27.9*

28.4***

20.9

48.3***

44.2*

ACCEPTED MANUSCRIPT

Table 4. Past 30-Day Symptoms and Behavior for First-Time and Repeat DUI Offenders.

M

ED

PT CE AC

34.7 26.7

23.3 23.3

CR

5.3

T

Western MA Repeat DUI Offenders (N = 160-164) % 14.0

7.2*

US

19.7

AN

Past 30-Day Experienced symptoms of depression Experienced symptoms of anxiety 25.0 Experienced 18.3 concentration/memory problems Experienced difficulty controlling 1.7 violent behavior Experienced serious thoughts of 1.7 suicide Prescribed medication for 11.9 psychological problems Used drugs other than 23.1 alcohol Past 30-Day M(SD) # of days drank alcohol 4.18 (7.08) # of days intoxicated 1.25 (2.83) # of days experienced alcohol 0.60 (2.96) problems # of days experienced other drug 0.10 (0.93) problems *Significantly different from first-time DUI offenders, p < .05.

Repeat DUI Offenders (N = 243-251) % 21.1

IP

First-time DUI Offenders (N = 117-121) % 19.0

7.0 4.7 14.0

28.8

23.3

M(SD) 2.82 (5.76)* 1.66 (4.58) 1.16 (4.32)

M(SD) 2.19 (4.38) 1.33 (3.48) 0.62 (2.60)

0.48 (2.92)

0.00 (0.00)

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Table 5. Contribution of Psychiatric Disorder Screens to Prediction of Repeat DUI Offender Status.

2=self-administered)

Step 2: Positive Screens Alcohol Use Disorder

(1.15 – 11.21)

(1.66 – 18.29)

1.25 (0.78 – 1.99) --

1.16 (0.68 – 1.96) -2.44* (1.16 – 5.14) 1.86 (0.97 – 3.56) 0.91 (0.49 – 1.67) 1.29 (0.74 – 2.25) 1.45 (0.75 – 2.77) 0.82 (0.36 – 1.87) 1.46 (0.70 – 3.05) 1.73 (0.73 – 4.10) 1.98 (0.97 – 4.03) 1.18 (0.47 – 2.95) 1.73 (0.84 – 3.54)

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Drug Use Disorder

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Generalized Anxiety Disorder Panic Disorder

AC

Tobacco Use Disorder

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Major Depressive -Disorder *** p < 0.001; ** p < 0.01; * p < 0.05

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59.65***

T

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2.05* (1.03 – 4.08)

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2.20 (0.82 – 5.88)

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ED

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CE

Intermittent Explosive Disorder Obsessive Compulsive Disorder Attention Deficit / Hyperactivity Disorder Oppositional Defiant Disorder Conduct Disorder

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PT

Post-Traumatic Stress Disorder Mania

IP

CR

Ethnicity (0=nonHispanic; 1=Hispanic) Condition (1=interview;

Past Year Model (Past Year Psychiatric Disorder Screens) Step 1 Odds Step 2 Odds Ratio Ratio (95% CI) (95% CI) Step χ2 --9.38 0.91 0.79 -(0.57 – 1.46) (0.47 – 1.31) 1.02 1.02 -(1.00 – 1.04) (1.00 – 1.04) 0.56 0.65 -(0.27 – 1.16) (0.31 – 1.36) 3.59* 4.09* -(1.15 – 11.21) (1.30 – 12.85) 1.25 1.14 -(0.78 – 1.99) (0.70 – 1.86) --35.57***

US

(0=white; 1=non-white)

AN

Race

M

Predictor Step 1: Control Variables Gender (0=male; 1=female) Age

Lifetime Model (Lifetime Psychiatric Disorder Screens) Step 1 Odds Step 2 Odds Ratio Ratio (95% CI) (95% CI) Step χ2 --9.38 0.91 1.22 -(0.57 – 1.46) (0.70 – 2.10) 1.02 1.03** -(1.00 – 1.04) (1.01 – 1.05) 0.56 0.64 -(0.27 – 1.16) (0.29 – 1.40) 3.59* 5.51** --

2.16** (1.35 – 3.45) 1.86 (0.75 – 4.64)

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Figure 1. Sample Diagram.

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Highlights:  This study compares psychiatric comorbidity in first-time and repeat DUI offenders.  Repeat DUI offenders were more likely to screen positive for 16 of 19 disorders.  Repeat DUI offenders were more likely to experience symptoms of multiple disorders.  First-time DUI offenders also experienced extensive psychiatric problems.  Number of positive screens was more predictive of repeat DUI than specific screens.