NESARC study , Critical Review

1. National Epidemiologic Survey on
Alcohol and Related Conditions
(NESARC): A CRITICAL REVIEW
Presenter: Amitkumar Chougule

2. INTRODUCTION
 National Comorbidity Survey: Baseline (NCS-1) Conducted from
1990-1992 (NCS-2) was a follow up study conducted between 2001
and 2002
 In 1992 United States conducted the National Longitudinal Alcohol
Epidemiologic Survey (NLAES)
 The World Health Organization International Consortium in
Psychiatric Epidemiology (ICPE), 2000
 2007 National Survey of Mental Health and Wellbeing, conducted by
the Australian Bureau of Statistics (ABS)

3. National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC):
 Household survey designed, conducted, and sponsored by
The National Institute on Alcohol Abuse and Alcoholism
(NIAAA)
 Largest and most comprehensive survey conducted on
alcohol use, alcohol use disorders, and their physical and
psychiatric disabilities

4. WHAT IS THE NEED FOR STUDY?
1. To determine the prevalence of alcohol abuse and dependence
in disadvantaged groups
2. Accurate information on comorbidity of alcohol abuse and
dependence with other specific mental disorders is important
3. Comorbidity of alcohol abuse or dependence with other
disorders controlling for the comorbidity of these disorders with
each other has not been addressed

5. CONTINUED…
4.Recent US and international surveys deviated from DSM-IV
criteria by skipping alcohol dependence criteria if respondents
did not satisfy alcohol abuse criteria
5.This caused about one third of 12-month cases and about
15% of lifetime cases of alcohol dependence to be missed
6.Determining whether treatment needs that were unmet in the
early 1990s are now better served

6. NESARC’s Key Goals
1. To determine the extent of alcohol use disorders (AUDs)
and their associated disabilities in the general population
2. To estimate changes over time in AUDs
3. To determine treatment related factors
4. To determine the extent of major alcohol-related mental
and physical disabilities

7.  First wave (Wave 1) 2001-2002 : baseline assessment for
prevalence data
 Second wave(wave 2) 2004–2005: follow up data
 Third wave: to be conducted……………
National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC)

8. Methodology
 The fieldwork for this survey was completed under NIAAA’s
direction by trained U.S. Census Bureau Field
Representatives through computer-assisted personal
interviews (CAPI) in face-to-face household settings

9.  The sample included 43,093 respondents ages 18 and older,
representing the civilian, non institutionalized adult
population in the United States, including all 50 States and
the District of Columbia
 The Wave 1 NESARC used a multistage stratified design in
which primary sampling units (PSUs) were stratified
according to Sociodemographic criteria

10.  Data collection for Wave 2 began in August 2004 and was
completed by September 2005
 The Wave 2 NESARC reinterviewed 34,653 of the 43,093
Wave 1 NESARC respondents
 Response rate was 81 percent

11. Data Coverage
 In both waves, the information was collected using the NIAAA
Alcohol Use Disorder and Associated Disabilities Interview
Schedule–Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV) Version (AUDADIS-IV)
 Fully structured diagnostic interview instrument
(questionnaire) designed for experienced lay interviewers
(Grant, Dawson, and Hasin 2001)

12. Measures used
 NESARC Alcohol Items:
Primary focus of the NESARC is ALCOHOL
Which includes:
1. Amounts and patterns of consumption
2. Experiences associated with drinking
3. Classification of alcohol use disorders
4. Family history of alcohol problems

13.  An alcoholic or problem drinker was defined for each
respondent during the interview as a person who has:
1. Physical or emotional problems because of drinking
2. Problems with a spouse, family, or friends because of drinking
3. Problems at work or school because of drinking
4. Problems with the police (like drunk driving) because of
drinking
5. Person who seems to spend a lot of time drinking or being
hung over

14. Alcohol Treatment
 A respondent’s lifetime and past-year treatment seeking
status was determined

15. Other NESARC Items
1. Basic Demographic and Background Information
2. Tobacco Use Status
3. Drug Use Status
4. Medical Conditions
5. DSM-IV Mood and Anxiety Disorders
6. DSM-IV Personality and Conduct Disorders

16. NESARC's UNIQUE DESIGN
 NESARC is unparalleled in a number of ways:
1. Large sample size of 43,093 people
2. Larger the sample size the more accurate the findings
3. Achievement of stable estimates of even rare conditions
4. Participants came from all walks of life and a variety of
ages

17.  The investigators were able to obtain data on people not
typically captured by household surveys
 To ensure that minority and special populations were well
represented in the sample, NESARC oversampled Blacks,
Hispanics, and young adults aged 18–24
 Survey produced enough minority respondents to answer
questions of race/ethnic disparities in comorbidity and access
to health care services
 NESARC’s unique design resulted in a rich dataset

18.  Several sources of non sampling error could have occurred
such as:
1. Interviewers recording wrong answers
2. Respondents providing incorrect information
3. Respondents inaccurately estimating requested information
4. Unclear survey questions misunderstood by the respondent
(measurement error)
5. Missed individuals(coverage error)
6. Missing responses (nonresponse error)
7. Forms lost, and data incorrectly keyed, coded, or recoded
(processing error)

19. Prevalence, Correlates, Disability,
and Comorbidity of DSM-IV Alcohol Abuse
and Dependence in the United States:
Results from NESARC
Deborah S. Hasin, PhD; Frederick S. Stinson, PhD; Elizabeth Ogburn,
MS; Bridget F. Grant, PhD, PhD

20. The Magnitude of the Problem and Trends
over Time
 Analysis using the data from NESARC and its predecessor
survey the 1991-1992 National Longitudinal Alcohol
Epidemiologic Survey (NLAES) showed trends in alcohol
abuse and dependence between 1991-1992 and 2001-2002
 Results:
1. Alcohol abuse increased from 3.03 percent to 4.65 percent
2. Dependence declined from 4.38 percent to 3.81 percent

21.  Increases in alcohol abuse were found in both men and
women, particularly among young Blacks and Hispanics
 Rates of dependence increased among men overall, young
Black women, and Asian men
 There was a decrease in the overall rate of dependence
 The reasons behind this rise in rates of abuse and
dependence among minority young adults were unclear and
will need further investigation
 This study underscores the importance of trends in alcohol
abuse and dependence

22. Prevalence OF AUDs
 The 12-month prevalence of DSM-IV
1. alcohol abuse - 4.7%
2. dependence - 3.8%
 12- month prevalence of any alcohol use disorder was 8.5%
 The lifetime prevalence of DSM-IV
1. alcohol abuse- 17.8%
2. dependence - 12.5%
 Total lifetime prevalence of any alcohol use disorder was 30.3%

23. Alcohol dependence was significantly more prevalent among:
1. Men
2. Whites
3. Native Americans
4. Younger and unmarried adults
5. Those with lower incomes

24.  Current alcohol abuse was more prevalent among:
1. Men
2. Whites
3. Younger and unmarried individuals
 Lifetime rates were highest among middle-aged Americans

25.  According to NIAAA’s low-risk drinking guidelines:
 Men may be at risk if they drink:
 More than 14 drinks per week or more than 4 drinks on any
day
 Women may be at risk if they drink:
 More than 7 drinks per week or more than 3 drinks on any day

26.  The prevalence of alcohol dependence with abuse increased
in a fairly linear fashion with frequency of exceeding daily
drinking limits
 The prevalence of dependence alone (no abuse) and abuse
alone (no dependence) peaked among persons who
exceeded the daily limits twice a week and then leveled off
 This data support the utility of the daily and weekly drinking
limits in predicting AUDs

27. Socio-demographic and clinical
characteristics
 The risk of continued/recurrent dependence increased with:
1. Ethanol intake
2. People with 10 or more life-time dependence symptoms
3. Positive histories of illicit drug use and personality disorders
 The risk of dependence decreased with:
1. Age
2. high-school graduation
3. reduced among women
4. non-Hispanic whites
5. married people

28. Evidence for a two-stage model of
dependence
 Twin studies suggest that substance initiation and
dependence are part of a complex two-stage process
 Some genetic influences are stage-specific acting on either
the transition from abstinence to initiation or on the transition
from use to dependence
 Family history of drug or alcohol problems is significantly
associated with initiation that does not progress to
dependence (i.e., conditional initiation)

29.  Family history of drug or alcohol problems is significantly
associated with dependence even after conditioning on
factors influencing initiation (i.e., conditional dependence)
 These results suggest that substance initiation and
dependence involve at least partially distinct familial factors
 The possibility that different genetic factors affect initiation
and dependence has important implications for control group
selection in case–control genetic association studies

30.  The researchers identified 5 subgroups of alcoholism:
1."Young-adult" subtype (31.5% of US alcoholics):
 Dependent on alcohol within 3 years of drinking onset
 low rates of abuse of other substances and family alcoholism
2."Young-antisocial" subtype (21.1% of US alcoholics):
 Dependent on alcohol within 3 years of drinking onset
 They tend to have antisocial personality disorder, multiple psychiatric
comorbidities, problems with other types of substance abuse and a
family history of alcoholism

31. 3."Functional" subtype (19.4% of US alcoholics):
 middle-aged, well-educated, good jobs
 dependent on alcohol for about 18 years
4."Intermediate-familial" subtype (18.8% of US alcoholics):
 middle-aged dependent on alcohol for 15 years
 family history of alcoholism and multiple comorbidities

32. 5."Chronic-severe" subtype (9.2% of US alcoholics):
 middle-aged
 Dependent on alcohol for about 13 years
 Tend to have a multigenerational family history of alcoholism
 Highest rates of other psychiatric disorders

33. ONSET AND COURSE OF DSM-IV ALCOHOL USE
DISORDERS
 Mean ages at onset of alcohol:
1. Abuse 22.5 years
2. Dependence 21.9 years
 Hazard rates for onset peaked at age 19 years and
decreased thereafter
 Mean durations of longest episodes of alcohol abuse and
dependence were 2.7 and 3.7 years

34.  Onset of drinking at a young age(< 14 years) has much
higher risk of :
1. Developing a problem with alcohol later in life
2. Dependence within 10 years of beginning drinking i.e
before age 25
3. Multiple episodes of dependence
4. Episodes of dependence followed by non dependence
5. Delinquency and criminal activity
6. Drinking and driving

35.  PRESCRIPTION DRUG MISUSE (PDM) AND ALCOHOL
DEPENDENCE:
Alcohol dependent and cannabis-users with (PDM) were
significantly more likely to report alcohol-related “risk-taking
behaviors” or “interpersonal troubles” than were those
without PDM

36.  The mean number of episodes among respondents with
multiple episodes of abuse and dependence was 5.2 and 5.1
respectively
 Mean duration of dependence episodes differed significantly
(P.01) between those with one episode (3.4 years) vs
multiple episodes (2.4 years)

37. TREATMENT FOR DSM-IV ALCOHOL USE
DISORDERS
 Those with lifetime alcohol dependence only 24.1% ever
received treatment
 Those with 12-month alcohol dependence only 12.1%
received alcohol treatment in the past year
 Treatment rates were lower than treatment rates 10 years
earlier

38. Among those with 12-month alcohol dependence:
1. 7.4%received help from 12-step (self-help) groups
2. 10.0% from any health professional other than 12-step
groups employee assistance programs, or clergy
3. 6.7% from physicians or other health professionals

39.  Of those with 12-month alcohol abuse:
1. 2.0% received help from 12-step groups
2. 0.0% (halfway houses) to 1.9% (any professional other
than 12-step groups, employee assistance programs, or
clergy)
 Lifetime professional treatment rates were 4.5% among
respondents with alcohol abuse and 20.1% among
respondents with alcohol dependence

40.  In the NESARC, the mean age of respondents first treatment
for dependence was 29.8 years
 8-year mean lag between onset and treatment
 The mean age of first treatment for abuse was 32.1years
 10-year mean lag between onset and treatment

41.  Characteristics that significantly (P.05) predicted
treatment:
1. For 12-month alcohol dependence the lowest income
category predicted treatment
2. For 12-month abuse those widowed, separated, or
divorced, those with less than high school education were
more likely to receive treatment

42. Reasons for not seeking alcohol
treatment
1. Should be strong enough to handle it alone
2. Thought problem would get better by itself
3. Stop drinking on my own
4. Did not think drinking problem was serious
5. Was too embarrassed to discuss it with anyone

43. RECOVERY
 25.0% of all US adults with prior-to-past-year (PPY) alcohol
dependence were still dependent in the past year
 27.3% were in partial remission
 10.5% met the criteria for alcohol abuse
 16.8% reported a subclinical array of dependence symptoms

44.  Half of all people with PPY dependence met the criteria for
full remission
 This includes asymptomatic risk drinkers (11.8%), low-risk
drinkers (17.7%) and abstainers (18.2%)
 Combining low-risk drinkers (Non abstinent remission NR)
and (abstinent remission AR) more than one-third (35.9%)
had a past-year status indicative of full recovery

45.  Among people with PPY dependence who were still
dependent in the year preceding interview just 28.8%
reported having received treatment
 Nearly one-quarter of PPY alcohol-dependent individuals had
achieved NR or AR in the past year without benefit of
treatment
 The rate of stable natural recovery (lasting 5 years) was
20.6%

46.  Entry into and exit from a first marriage each increased the
likelihood of non-abstinent recovery during the first 3 years
after those events occurred
 The likelihood of abstinent recovery was more than doubled
in the 3 years after first becoming a parent

47.  AR was more common among:
1. Blacks
2. People with relatively severe dependence
3. life-time smokers
4. People with a history of treatment for alcohol problems
 NR was more common among persons who:
1. Attended college
2. Reported non-dependent use of illicit drugs

48.  There is a wide range of recovery from alcohol dependence
in the general population, from partial remission to full
abstinence
 Track of this disease is not clear-cut
 some people appear to recover from alcoholism without
formal treatment
 Others may cycle into and out of dependence throughout
their lifetime despite repeated attempts to achieve sobriety

49. RELAPSE:
 Relapse by wave 2:
1. 51.0% of the Wave 1 asymptomatic risk drinkers
2. 27.2% of low-risk drinkers
3. 7.3% of abstainers
 Abstinence represents the most stable form of remission for
most recovering alcoholics
 Need for better approaches for maintaining recovery among
young adults in remission who are at high risk of relapse

50. CRITIQUE
 No conclusions can be drawn from findings regarding:
1. The effectiveness of treatment
2. Overall relationship between drinking status and treatment
status
 It is not clear what constituted ‘treatment’ for the NESARC
respondents
 There was a substantial recovery rate without treatment
 About half of all recoveries involved low risk drinking rather
than abstinence

51.  Necessity of a small intensively studied sample whom the
investigator has actually met in case of confidential
information
 To study the information regarding return to controlled
drinking one needs to:
1. Include other informants
2. To conduct observations over time until the true
information emerges
3. Can be ruled out on a case-by-case basis

52.  This study could not provide any guidelines concerning who
really must stop drinking in order to recover from
dependence, and who can recover stably from dependence
even while drinking moderately

53.  What might constitute appropriate services:
1. Public information and education showing that recovery from
alcohol problems without treatment is not only possible but
also frequent
2. For those who are not successful the attempt may increase
their readiness to seek help
3. Further study alternatives to abstinence
4. Attracting people with less serious alcohol problems to
treatment
5. Training health-care providers and addiction counselors to
competently provide moderation services

54. ASSOCIATIONS BETWEEN DSM-IV
ALCOHOL USE DISORDERS AND
OTHER PSYCHIATRIC DISORDERS
CONTROLLING FOR SOCIODEMOGRAPHIC
CHARACTERISTICS AND OTHER COMORBIDITY

55. 1. 12 month alcohol abuse remained strongly and significantly
associated with substance use disorders (OR 1.8)
2. But not with other Axis I disorders
3. Was negatively associated with schizoid PD and Bipolar I disorder
4. A similar pattern was observed for lifetime abuse

56.  12 month alcohol dependence remained strongly
associated with:
1. Substance use disorders (ORs=3.4-7.5)
2. bipolar disorders but with lower ORs (1.9, 2.0)
 Significant association with 2 Axis II disorders:
1. Histrionic PD
2. Antisocial PD

57.  Lifetime DSM-IV alcohol dependence remained positively
although less strongly associated with :
1. Substance use disorders
2. Most mood and anxiety disorders
3. Paranoid, histrionic, and antisocial PDs

58.  Rates of any PD were greater among respondents with any
drug abuse (37.8%) and any drug dependence (69.5%) than
among respondents with alcohol abuse (19.8%) and alcohol
dependence (39.5%)
 Patients with comorbid alcohol and drug use disorders and
PDs can be expected to require treatment that is more
extensive and of longer duration
 Modified psychoanalytic psychotherapy focused or targeted
on particular features of PDs should be used

59.  Nicotine dependence was reported by 48% of the alcohol-
dependent respondents
 They reported higher lifetime rates of:
1. Panic disorder
2. Specific and social phobia
3. Generalized anxiety disorder
4. Major depressive episode
5. Manic disorder
6. Suicide attempt
7. Antisocial personality disorder
8. All addictive disorders

60. Probability of transitioning to substance dependence
among substance users
1. After the first year of substance use onset the probability of
transition to dependence was highest for COCAINE users
2. The probability estimates of transition to dependence a
decade after use onset was highest for NICOTINE users
3. Lifetime cumulative estimated probability of use to
dependence was highest for NICOTINE users

61. Predictors of transition from substance use to
dependence
 Socio-demographic predictors :
1. Females were more likely than males to transition from
nicotine use to dependence
2. Males were more likely to transition from alcohol and
cannabis use to dependence
3. US-born Individuals were more likely than foreign-born
individuals to report transition from nicotine and alcohol
use to dependence

62. Psychopathological and substance use-related
predictors
 A history of any mental disorder strongly predicted the
development of substance dependence
 Nicotine , alcohol, cannabis or cocaine users diagnosed with
a mood disorder or a PD were more likely to become
dependent on those substances

63.  Nicotine, alcohol or cannabis users diagnosed with an
anxiety disorder showed an increased risk of becoming
dependent on these substances
 A lifetime diagnosis of a psychotic disorder increased the
risk of developing nicotine dependence among nicotine users

64.  Having a history of SUD predicted a further development of
an additional SUD
 Individuals diagnosed with nicotine dependence were more
likely to develop alcohol dependence among alcohol users
and cannabis dependence among cannabis users

65.  Family history of SUD increased the risk of transition from
nicotine or alcohol use to dependence
 The cumulative probability of transition to dependence was
highest for nicotine users and least for cannabis users
 The transition to cannabis or cocaine dependence occurred
faster than the transition to nicotine or alcohol dependence

66. Cannabis use:
 Later onset cannabis use:
1. Religious and pro-social activities are negatively
associated
2. Divorce, alcohol and nicotine-related problems are
positively associated
 Social anxiety disorder (SAD) was more likely to be related to
cannabis dependence than abuse

67. Substance use disorders among inhalant
users:
 The lifetime prevalence of SUDs among adult inhalant users
was 96%
 Compared with substance users without a history of inhalant
use inhalant users:
1. Initiated use of cigarettes, alcohol, and almost all other
drugs at younger ages
2. Higher lifetime prevalence of nicotine, alcohol, and any
drug use disorder

68. Nonmedical prescription drug use and drug
use disorders:
 The odds of nonmedical prescription drug use and drug use
disorders were greater among:
1. men, Native Americans, young and middle-aged
2. widowed/separated/divorced or never married
 Abuse/dependence liability was greatest for amphetamines
 Nonmedical prescription drug use disorders were highly
comorbid with other Axis I and II disorders
 The majority of individuals with nonmedical prescription drug
use disorders never received treatment

69. Epidemiology of MOOD
Disorders
Results From the National Epidemiologic
Survey on Alcoholism and Related Conditions
Deborah S. Hasin, PhD; Renee D. Goodwin, PhD; Frederick S. Stinson,
PhD; Bridget F. Grant, PhD, PhD

70. PREVALENCE AND SOCIODEMOGRAPHIC
CORRELATES
 Prevalence rates of DSM-IV were:
 Major depressive disorder:
1. Lifetime 13.23%
2. 12-month 5.28%
 Bipolar 1 lifetime and 12-month were 3.3% and 2.0%
 Bipolar 2 lifetime and 12-month rates were 1.1% and 0.8%

71.  Women showed a significantly higher risk for MDD
 MDD had strongest risk among those 45 to 64 years old
 Risk of MDD did not differ by education, region, or urbanicity

72. ONSET, COURSE, AND TREATMENT
 Mean age at onset of MDD was 30.4 years
 The hazard for onset of MDD increased sharply between
ages 12 and 16 years and continued to increase up to the
early 40s when it began to decline
 Among respondents with lifetime MDD a mean of 4.7
episodes was reported with median duration of 24.3 weeks
for the longest (or only) episode

73. PREVALENCE OF DSM-IV AXIS I AND II
DISORDERS AMONG RESPONDENTS WITH MDD
Among those with MDD in the prior 12 months:
1. 14.1% had an alcohol use disorder
2. 4.6% had a drug use disorder
3. 26.0% had nicotine dependence
4. 36.1% had at least 1 anxiety disorder
5. The prevalence of any PD was high (37.9%) and quite
variable from PD to PD

74. Among those with lifetime MDD:
1. 40.3% had an alcohol use disorder
2. 17.2% had a drug use disorder
3. 30.0% had nicotine dependence
4. 40% had an anxiety disorder
5. 30% had a PD

75. Conclusions about MDD from NESARC
 Average duration was almost 6 months longer than the
previous estimate of 4 months
 Almost half the respondents with MDD thought about suicide
or wanted to die
 The findings disclose higher risk for MDD among Native
Americans
 NESARC findings of lower risk for Hispanics and Asians
contributes new information

76.  Strong association of MDD with dependence on alcohol,
drug, and nicotine, in contrast with a weak relationship of
MDD with substance abuse
 These results highlight the importance of not lumping abuse
and dependence together when studying comorbidity

77.  The comorbidity of substance dependence with MDD
predicts poor outcome among patients
 Treating MDD that is comorbid with alcohol or drug
dependence is now recommended

78. Panic attacks and suicide:
 Panic attacks appear to be an independent risk factor for
suicide attempt among depressed individuals with and
without suicidal ideation
 Assessment panic symptoms may improve prediction of
suicide attempts

79.  The presence of atypical features during an MOOD
DISORDER EPISODE (MDE) was associated with greater
rates of lifetime psychiatric comorbidity like:
1. Alcohol abuse
2. Drug dependence
3. Dysthymia
4. Social anxiety disorder
5. Specific phobia
6. Personality disorder

80.  MDE with atypical features was associated with:
1. Female gender
2. Younger age at onset
3. More Mood disorder episodes
4. Greater episode severity and disability
 Higher rates of:
1. Family history of depression
2. Bipolar I disorder
3. Suicide attempts
4. Larger mental health treatment-seeking rates

81.  Variables determined to be predictors of BD I :
1. unemployment (OR = 0.6)
2. Taking medications for depression (OR = 1.7)
3. History of a suicide attempt (OR = 1.8)
4. weight gain (OR = 1.7)
5. Fidgeting (OR = 1.5)
6. Feelings of worthlessness (OR = 1.6)
7. Difficulties with responsibilities (OR = 2.2)
8. Presence of specific phobias (OR = 1.8)
9. Cluster C traits (OR = 1.4)

82.  The mean age of BD-I subjects with CVD and HTN was 14
and 13 years younger, respectively, than controls with CVD
and HTN
 Adults with BD-I are at increased risk of CVD and HTN,
prevalent over a decade earlier than non-BD adults

83. Role of self-medication in the development of
comorbid mood and drug use disorders
 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

84. The Intricate Link Between
Violence and Mental Disorder
Results From the National Epidemiologic Survey on
Alcohol and Related Conditions
Eric B. Elbogen, PhD; Sally C. Johnson, MD

85. Results provide empirical evidence that :
 Severe mental illness is not a robust predictor of future
violence
 People with co occurring severe mental illness and
substance abuse/ dependence have a higher incidence of
violence than people with substance abuse/dependence
alone

86. CRIMINAL VICTIMIZATION:
 More than 1-in-25 adults in the United States (4.1%) reported
past-year criminal victimization
 Risks for criminal victimization:
1. Lower levels of income
2. Living in urban areas
3. Separated or divorced
 Crime victims evidenced significantly increased rates of:
1. alcohol, cocaine, and opioid use disorders
2. Paranoid personality disorder, major depressive disorder,
and a family history of antisocial behavior

87. Psychiatric disorders among foreign-born and US-
born Asian-Americans (AAs) in a US national survey
 Foreign-born AAs had significantly lower risk for all classes of
disorder compared with US-born AAs (OR = 0.16–0.59)
 Risk for all classes of disorder was lowest for those foreign-
born AAs who arrived in the US as adults
 Developmental timing and the duration of experience in the
US contribute to increases in risk

88. An invariant dimensional liability model of
gender differences in mental disorder
prevalence: Evidence from NESARC
 Gender differences in prevalence were systematic such that
women showed higher rates of mood and anxiety disorders,
and men showed higher rates of antisocial personality and
substance use disorders
 women showed a higher mean level of internalizing, while
men showed a higher mean level of externalizing

89. Pathological gambling
 Three classes (or subtypes) of gamblers:
1. Behaviorally conditioned
2. Emotionally vulnerable
3. Antisocial impulsivist
 Blaszczynski and Nower's (2002) pathways model may
eventually contribute to the development of more reliable and
valid methods of identifying people who are at risk of
developing gambling problems

90. Physical Punishment and Mental Disorders:
 Approximately 2% to 5% of Axis I disorders and 4% to 7% of
Axis II disorders were attributable to harsh physical
punishment.
 Harsh physical punishment in the absence of child
maltreatment is associated with mood disorders, anxiety
disorders, substance abuse/dependence, and personality
disorders in a general population sample

91. Association Between Peptic Ulcer and
Personality Disorders:
 All seven personality disorders were associated with stomach
ulcer
 Participants with ulcer were five times more likely to have
more than three personality disorders than participants
without ulcer

92. CONCLUSION
 NESARC is an example of a large, random, representative
survey of adults living in the United States
 This survey addressed all aspects of alcohol use—from
determining when a respondent took his or her first drink to
discovering whether he or she had experienced co-occurring
mental health problems

93.  NESARC data have several practical applications like
defining the intricate relationship between alcohol use and
comorbidity, to study high-risk drinking patterns, to design
better-targeted treatment approaches, and to monitor
recovery from AUDs
 As more researchers take advantage of the richness of this
dataset, more knowledge will be gained, helping to advance
prevention efforts and treatment interventions in the alcohol
field