Jennifer Robinson

Self-medication of mood disorders with alcohol and drugs in the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND Using alcohol or drugs to reduce emotional distress (self-medication) has been proposed as an explanation for the high comorbidity rates between anxiety and substance use disorders. Self-medication has been minimally studied in mood disorders despite equally high rates of alcohol and drug use. METHODS Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large (n=43,093, age 18 years and older) nationally representative survey of mental illness in community-dwelling adults. Prevalence rates of self-medication were determined for DSM-IV mood disorders: dysthymia, major depressive disorder, bipolar I disorder, and bipolar II disorder. Multiple logistic regression generated odds ratios for the association between each category of self-medication and anxiety and personality disorders. RESULTS Almost one-quarter of individuals with mood disorders (24.1%) used alcohol or drugs to relieve symptoms. The highest prevalence of self-medication was seen in bipolar I disorder (41.0%). Men were more than twice as likely as women to engage in self-medication (Adjusted Odds Ratio=2.18; 95% Confidence Interval 1.90-2.49). After controlling for the effects of substance use disorders, self-medication was associated with higher odds of comorbid anxiety and personality disorders when compared to individuals who did not self-medicate. LIMITATIONS Cross-sectional design. CONCLUSIONS The use of alcohol and drugs to relieve affective symptoms is common among individuals with mood disorders in the general population, yet is associated with substantial psychiatric comorbidity. These findings may help clinicians identify a subgroup of people with mood disorders who suffer from a higher mental illness burden.

Self-medication of anxiety disorders with alcohol and drugs: Results from a nationally representative sample.

Self-medication--the use of alcohol or drugs in an attempt to reduce anxiety--has often been invoked as an explanatory mechanism for the high co-occurrence of anxiety and substance use disorders (for reviews, see Allan, C. A. (1995). Alcohol problems and anxiety disorders-A critical review. Alcohol & Alcoholism, 30(2), 145-151; Kushner, M. G., Abrams, K., & Borchardt. (2000). The relationship between anxiety disorders and alcohol use disorders: A review of major perspectives and findings. Clinical Psychology Review, 20(2), 149-171). The current study expands upon previous self-medication research by: (1) examining prevalence and comorbidity of self-medication for anxiety disorders (panic disorder, social phobia, specific phobia, and generalized anxiety disorder); (2) using a nationally representative sample (National Epidemiologic Survey on Alcohol and Related Conditions; N=43,093) to do so; and (3) by differentiating self-medication with alcohol from self-medication with drugs. Prevalence rates ranged from 18.3% (self-medication with alcohol for generalized anxiety disorder) to 3.3% (self-medication with both alcohol and drugs for specific phobia and panic disorder without agoraphobia). Multiple logistic regression analyses determined that self-medication with alcohol was associated with increased likelihood of any mood or personality disorder diagnosis, while self-medication with both alcohol and drugs further increased these associations over and above self-medication with alcohol alone. Findings remained significant after adjusting for sociodemographic and substance use disorder variables, which suggests that independently of substance use disorders, self-medication can be viewed as a marker of severity.

Population-Attributable Fractions of Axis I and Axis II Mental Disorders for Suicide Attempts: Findings From a Representative Sample of the Adult, Noninstitutionalized US Population

OBJECTIVES We aimed to determine the percentage of suicide attempts attributable to individual Axis I and Axis II mental disorders by studying population-attributable fractions (PAFs) in a nationally representative sample. METHODS Data were from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (NESARC; 2004-2005), a large (N = 34 653) survey of mental illness in the United States. We used multivariate logistic regression to compare individuals with and without a history of suicide attempt across Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorders (anxiety, mood, psychotic, alcohol, and drug disorders) and all 10 Axis II personality disorders. PAFs were calculated for each disorder. RESULTS Of the 25 disorders we examined in the model, 4 disorders had notably high PAF values: major depressive disorder (PAF = 26.6%; 95% confidence interval [CI] = 20.1, 33.2), borderline personality disorder (PAF = 18.1%; 95% CI = 13.4, 23.5), nicotine dependence (PAF = 8.4%; 95% CI = 3.4, 13.7), and posttraumatic stress disorder (PAF = 6.3%; 95% CI = 3.2, 10.0). CONCLUSIONS Our results provide new insight into the relationships between mental disorders and suicide attempts in the general population. Although many mental illnesses were associated with an increased likelihood of suicide attempt, elevated rates of suicide attempts were mostly attributed to the presence of 4 disorders.

A Prospective Assessment of Reports of Drinking to Self-medicate Mood Symptoms With the Incidence and Persistence of Alcohol Dependence

IMPORTANCE Mood disorders and alcohol dependence frequently co-occur. Etiologic theories concerning the comorbidity often focus on drinking to self-medicate or cope with affective symptoms. However, there have been few, if any, prospective studies in population-based samples of alcohol self-medication of mood symptoms with the occurrence of alcohol dependence. Furthermore, it is not known whether these associations are affected by treatment or symptom severity. OBJECTIVE To evaluate the hypothesis that alcohol self-medication of mood symptoms increases the probability of subsequent onset and the persistence or chronicity of alcohol dependence. DESIGN Prospective study using face-to-face interviews-the National Epidemiologic Survey on Alcohol and Related Conditions. SETTING Nationally representative survey of the US population. PARTICIPANTS Drinkers at risk for alcohol dependence among the 43 093 adults surveyed in 2001 and 2002 (wave 1); 34 653 of whom were reinterviewed in 2004 and 2005 (wave 2). MAIN OUTCOMES AND MEASURES Association of alcohol self-medication of mood symptoms with incident and persistent DSM-IV alcohol dependence using logistic regression and the propensity score method of inverse probability of treatment weighting. RESULTS The report of alcohol self-medication of mood symptoms was associated with an increased odds of incident alcohol dependence at follow-up (adjusted odds ratio [AOR], 3.10; 95% CI, 1.55-6.19; P = .002) and persistence of dependence (AOR, 3.45; 95% CI, 2.35-5.08; P < .001). The population-attributable fraction was 11.9% (95% CI, 6.7%-16.9%) for incident dependence and 30.6% (95% CI, 24.8%-36.0%) for persistent dependence. Stratified analyses were conducted by age, sex, race/ethnicity, mood symptom severity, and treatment history for mood symptoms. CONCLUSIONS AND RELEVANCE Drinking to alleviate mood symptoms is associated with the development of alcohol dependence and its persistence once dependence develops. These associations occur among individuals with subthreshold mood symptoms, with DSM-IV affective disorders, and for those who have received treatment. Drinking to self-medicate mood symptoms may be a potential target for prevention and early intervention efforts aimed at reducing the occurrence of alcohol dependence.

Reports of drinking to self-medicate anxiety symptoms: longitudinal assessment for subgroups of individuals with alcohol dependence.

Self‐medication with alcohol is frequently hypothesized to explain anxiety and alcohol dependence comorbidity. Yet, there is relatively little assessment of drinking to self‐medicate anxiety and its association with the occurrence or persistence of alcohol dependence in population‐based longitudinal samples, or associations within demographic and clinical subgroups.

Correlates of self-medication for anxiety disorders: results from the National Epidemiolgic Survey on Alcohol and Related Conditions.

Self-medication is a common behavior among individuals with anxiety disorders, yet few studies have examined the correlates of this behavior. The current study addresses this issue by exploring the pattern of mental health service use and quality of life among people who self-medicate for anxiety. Data came from the National Epidemiologic Survey on Alcohol and Related Conditions and was limited to the subsample of individuals meeting criteria for an anxiety disorder in the past 12 months (n = 4880). Multiple regression analyses compared 3 groups–(1) no self-medication, (2) self-medication with alcohol, and (3) self-medication with drugs, on mental health service use and quality of life. After adjusting for potentially confounding covariates, individuals who engaged in self-medication had significantly higher service use compared with people with anxiety disorders who did not self-medicate (adjusted odds ratio = 1.41, 95% CI = 1.06–1.89). Self-medication was also associated with a lower mental health-related quality of life compared with those who did not self-medicate. Clinicians should recognize and respond to the unique needs of this particular subpopulation of individuals with anxiety disorders.

The relation between nicotine dependence and suicide attempts in the general population.

Objective: There has been much debate as to whether nicotine is a risk factor for suicidal behaviour. This study sought to examine the relation between nicotine dependence and suicide attempts in a population-based sample of adults. Method: Our study used the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (NESARC; 2004–2005), a large (n = 34 653) nationally representative survey of community-dwelling American adults. Multiple logistic regression analyses examined the relation between suicide attempts and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, nicotine dependence, compared with nonusers of nicotine. Associations between suicide attempts and other measures of nicotine use (nicotine cessation, age of first use, frequency, and amount of use) were also examined. Results: Lifetime (AOR 1.78; 95% CI 1.48 to 2.15) and past-year nicotine dependence (AOR 1.77; 95% CI 1.02 to 3.06) were independently associated with lifetime and past-year suicide attempts, respectively, even after adjusting for sociodemographic factors, other mental disorders, and physical disease. Nicotine dependence cessation was associated with a decreased likelihood of suicide attempt compared with people currently dependent on nicotine (AOR 0.15; 95% CI 0.05 to 0.43). Greater amount of daily cigarette use was associated with suicide attempts in the model that adjusted for sociodemographic factors and other mental disorders (AOR 1.53; 95% CI 1.05 to 2.24). Conclusions: Nicotine dependence is associated with suicide attempts, independently of comorbid mental disorders and physical disease. The association attenuates when a person ceases using nicotine, suggesting a state, rather than trait, effect. These findings provide evidence for additional concern regarding the deleterious health effects of tobacco.

A longitudinal investigation of the role of self-medication in the development of comorbid mood and drug use disorders: findings from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

OBJECTIVE To examine whether self-medication with drugs confers risk of comorbid mood and drug use disorders. METHOD A longitudinal, nationally representative survey was conducted by the National Institute on Alcohol Abuse and Alcoholism. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) assessed DSM-IV-TR psychiatric disorders, self-medication, and sociodemographic variables at 2 time points. A total of 34,653 adult, US participants completed both waves of the survey. Wave 1 was conducted between 2001 and 2002, and Wave 2 interviews took place 3 years later (2004-2005). Logistic regression and population attributable fractions were calculated to obtain estimates of the association between self-medication and incident disorders. RESULTS Logistic regression analyses revealed that self-medication with drugs conferred a heightened risk of new-onset drug dependence among those with baseline mood disorders (adjusted odds ratio [AOR] = 7.65; 95% CI, 3.70-15.82; P < .001) and accounted for over 25% of incident drug dependence disorders among people with mood disorders. Among those with comorbid mood and drug use disorders at baseline, self-medication with drugs was associated with the persistence of drug abuse (AOR = 2.47; 95% CI, 1.34-4.56; P < .01), accounting for over one-fifth of the persistence of drug use disorders at 3-year follow-up. CONCLUSIONS Self-medication with drugs among individuals with mood disorders confers substantial risk of developing incident drug dependence and is associated with the persistence of comorbid mood and drug use disorders. These results clarify a pathway that may lead to the development of mood and drug use disorder comorbidity and indicate an at-risk population, with potential points of intervention for prevention of comorbidity.

A longitudinal population-based study exploring treatment utilization and suicidal ideation and behavior in major depressive disorder

BACKGROUND This study aimed to longitudinally examine the relationship between treatment utilization and suicidal behavior among people with major depressive disorder in a nationally representative sample. METHODS Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Wave 1: N=43,093; Wave 2: N=34,653). Suicidal and non-suicidal individuals at Wave 1 were compared based on subsequent treatment utilization. Suicidal behavior at Wave 2 was compared between people with major depressive disorder who had sought treatment at Wave 1 versus those that had not. RESULTS Individuals with past year major depressive disorder at Wave 1 who attempted suicide were more likely to be hospitalized at follow up compared to non-suicidal people with major depressive disorder [adjusted odds ratio (AOR)=4.46; 95% confidence interval [95% CI]: 2.54-7.85]; however, they were not more likely to seek other forms of treatment. Among those with past year major depressive disorder who sought treatment at baseline, visiting an emergency room (AOR=3.08; 95% CI: 1.61-5.89) and being hospitalized (AOR=2.41; 95% CI: 1.13-5.14), was associated with an increased likelihood of attempting suicide within 3 years even after adjusting for mental disorder comorbidity, depression severity, and previous suicidal behavior. LIMITATIONS Unable to draw conclusions about completed suicide or adequacy of treatment. CONCLUSIONS Suicidal behavior does not lead individuals with major depressive disorder to seek treatment with professionals or use antidepressant medications; instead, they are more likely to use emergency services. These findings suggest that treatment efforts for people with major depressive disorder who are suicidal need improvement.

The effect of Avoidant Personality Disorder on the persistence of Generalized Social Anxiety Disorder in the general population: results from a longitudinal, nationally representative mental health survey

Background: The primary objective of this study was to prospectively examine the role of Avoidant Personality Disorder (AvPD) as a determinant in the outcome of Generalized Social Anxiety Disorder (GSAD) using Wave 2 of the National Epidemiologic Survey of Alcohol and Related Conditions 3 years later. Method: This study analyzed data from Waves 1 and 2 of the NESARC (n = 34,653). GSAD was operationalized based on the DSM‐IV definitions of this SAD subtype. Results: Logistic regression analyses indicated that AvPD significantly predicted the persistence of GSAD, even after adjusting for a number of important sociodemographic variables and other psychiatric comorbidity. AvPD did not significantly predict outcome in non‐generalized SAD. Conclusions: AvPD can influence the course of GSAD in adulthood. Specific personality dimensions may underlie and explain the similarities between AvPD and GSAD. Self‐criticism could be a shared feature of both AvPD and GSAD and could represent an important psychological marker of poor prognosis in comorbid GSAD and AvPD. Depression and Anxiety 28:250–255, 2011.  © 2011 Wiley‐Liss, Inc.