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Psychiatric and Substance Use Disorders in South Florida
Racial/Ethnic and Gender Contrasts in a Young Adult Cohort
R. Jay Turner, PhD;
Andres G. Gil, PhD
Arch Gen Psychiatry. 2002;59:43-50.
ABSTRACT
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Background Prevalence rates of psychiatric and substance use disorders among young
adults in South Florida are presented. Unique aspects of the study include
the large sample size, its ethnic diversity, and the fact that a substantial
proportion of Hispanic participants were foreign born.
Methods This study builds on a previous cohort study of students who entered
middle school in 1990. A random subsample of this representative cohort (N
= 1803) was interviewed between 1998 and 2000 when most were between 19 and
21 years of age. Disorders were assessed through computer-assisted personal
interviews utilizing the DSM-IV version of the Michigan
Composite International Diagnostic Interview.
Results More than 60% of the sample met lifetime criteria for 1 or more study
disorders, and 38% did so within the preceding year. Childhood conduct and
major depressive and alcohol abuse disorders were the most prevalent. Although
rates of affective and anxiety disorders in females were double that in males,
this gender difference disappeared when attention-deficit/hyperactivity disorder,
conduct disorders, and antisocial personality disorders were also considered
(46.6% vs 45.7% for females vs males, respectively). Substantially lower rates
were observed among African Americans for depressive disorders and substance
abuse and dependence. Among Hispanics, rates tend to be lower among the foreign-born
in comparison with their US-born counterparts, particularly for the substance
disorders.
Conclusions The documented presence of psychiatric and substance disorders in middle
and high school populations emphasizes the importance of prevention efforts
in school settings. Research on the origins of ethnic and nativity differences
is called for.
INTRODUCTION
CREDITABLE information on the community prevalence and demographic correlates
of psychiatric and substance use disorders has been available in published
form for little more than a decade. Based on data obtained from 5 separate
and largely urban sites, the Epidemiologic Catchment Area Study (ECA) provided
estimates of lifetime and current psychiatric and substance use disorders
within and across African American, Hispanic, and non-Hispanic white subpopulations.1 Subsequently, the National Comorbidity Survey (NCS)2 employed a nationally representative sample of more
than 8000 persons between the ages of 15 and 54 to provide estimates of the
prevalence of psychiatric and substance use disorders and their social and
ethnic distributions. A summary of the ECA and NCS findings has recently been
presented by Tohen et al.3 Recent advances
have also been made toward estimating the community burden of substance use
and psychiatric disorders among children and adolescents 9 to 18 years of
age.4-7
These studies have been of immense theoretical and practical significance
because they have (1) produced estimates of the true prevalence of specific
psychiatric disorders in the community using well-defined diagnostic criteria;
(2) provided fundamental information on the chronicity, course, and comorbidity
of psychiatric disorders; (3) provided a basis for estimating the extent and
nature of unmet service needs; and (4) identified subpopulations most in need
of, or who might benefit most from prevention efforts.
This article is based on a new study within this tradition. It presents
findings on the prevalence and demographic distributions of psychiatric and
substance use disorders among a representative cohort of 1803 young adults.
Most participants (93%) were between 19 and 21 years of age when interviewed
between 1998 and 2000. The results constitute a unique contribution in several
respects. First, we believe that these data are from the largest sample within
this age range so far studied in the United States. Second, this is among
the first large-scale community studies to estimate prevalence rates based
on DSM-IV criteria. Most significantly, half of this
sample is composed of the understudied and quite distinct Hispanic population
of South Florida. Specifically, the sample was drawn such that approximately
25% were of Cuban origin, 25% were other Caribbean basin Hispanic, 25% were
African American, and 25% were non-Hispanic white. In addition, a substantial
proportion of Hispanic participants were foreign born (44.5%), a factor that
has been shown to be relevant to mental health and substance abuse risk.8-10
Our approach in drawing this sample is in accord with a growing consensus
in the field that race is more of a social than a biological categorization
akin to ethnic status,11 and that there are
important cultural variations within ethnic statuses. In an effort to minimize
the effects of such variations on results, we have distinguished Cubans from
other Hispanics and limited inclusion in the latter category to Hispanics
from countries in the Caribbean basin. For the same reason, Haitians and other
Caribbean black participants were excluded in forming the African American
subsample. Because of our interest in the effects of immigration and immigration
status, we have also excluded Puerto Ricans from the "other Hispanic" category.
METHODS
SAMPLE
This study builds on a previous 3-wave investigation based in the Miami-Dade
public school system.8 All 48 of the county's
public middle schools and all 25 public high schools as well as alternative
schools had participated. Questionnaires were administered annually between
1990 and 1993 beginning in grades 6 and 7 and finishing when participating
students were in grades 8 and 9. Consent forms were sent to parents of the
total population of 9763 male students scheduled to enter sixth and seventh
grades, and of 669 female students from 6 schools selected to approximate
the overall ethnic composition of county middle schools. Of these 10 432
prospective participants, completed questionnaires were obtained from 7386
at wave 1, from 6646 at wave 2, and from 5924 at wave 3. Detailed analyses
provided assurance that wave 1 participants were highly representative of
the population from which they were drawn and that this was also true for
the wave 3 participants, despite a nearly 20% attrition across the 3 data
points.8
Within the confines of ethnicity criteria, all female participants in
the earlier investigation (n = 410), and a random sample of 1273 male participants,
were ultimately selected for follow-up. Because a relatively small number
of girls were included in the parent study, a supplementary sample was randomly
drawn from the Miami-Dade county 1990 sixth- and seventh-grade class roster. Figure 1 summarizes the results of fieldwork
efforts. Overall, 70.1% of those we searched for and attempted to recruit
to the study were successfully interviewed. By far, the greatest loss occurred
among the new sample of girls who had no involvement in the early-adolescent
study. A success rate of 76.4% was achieved among those in the original sample,
despite the fact that many had left home for college or for other reasons.
Those interviewed were compared with the total sample of individuals
drawn from the original study population on 28 early-adolescent behaviors
and family characteristics of possible relevance to mental health or substance
abuse risk (analyses not shown). No statistically significant differences
were observed. Comparisons were also made with respect to school dropout.
Among those interviewed, 20.5% reported that they had dropped out of high
school. This corresponds closely with rates reported by the school board on
the same student cohort of 21.1% for boys and 15.2% for girls (data available
at:
http://www.dade.k12.fl.us/eema/Abstract%202000/Abstract_2000_Site/index.htm, accessed
November 28, 2000). These comparisons and the 76.4% follow-up success rate
allow the conclusion that our sample is representative of the population from
which it was drawn. In contrast, the 58.2% success rate with the supplementary
sample of new girls is disappointing, and analyses revealed a significant
parental socioeconomic status bias associated with these losses. To correct
for this bias, female participants have been differentially weighted in all
analyses to achieve a distribution on socioeconomic status that approximates
that observed for male participants. Because we sampled so as to achieve roughly
equal numbers of white non-Hispanic, Cuban, other Hispanic, and African American
participants (except where results are presented by ethnicity), the data have
also been weighted to population values with respect to ethnicity and gender.
DIAGNOSTIC ASSESSMENT
Data on the lifetime prevalence and 1-year prevalence of psychiatric
and substance use disorders were obtained through computer-assisted personal
interviews that allowed estimation of DSM-IV diagnoses.
Our basic instrument was the Michigan Composite International Diagnostic Interview
(CIDI), which was employed in the NCS.2 The
CIDI is a fully structured interview based substantially on the Diagnostic
Interview Schedule (DIS)12 and designed to
be administered by nonclinicians trained in its use.13-14
Using the Michigan CIDI, as updated by NCS researchers to cover DSM-IV criteria, we assessed major depression, dysthymia, generalized
anxiety disorder, social phobia, panic disorder, alcohol abuse and dependence,
drug abuse and dependence, posttraumatic stress disorder (PTSD), and antisocial
personality disorder. The latter 2 modules had been borrowed from the DIS12 for the NCS. Field trials of the original CIDI had
documented good reliability and validity for all of the CIDI diagnoses considered
here.15 Evidence for the validity of the Michigan
CIDI diagnostic estimates, evaluated against structured clinical reinterviews,16 have been reported for most NCS disorders, including
affective disorders,17 anxiety disorders,18-19 addictive disorders,20-21
and posttraumatic stress disorder.22
Along with the Michigan CIDI, our assessment instrument23
included a reliable module24 taken from the
revised DIS25 to assess attention-deficit/hyperactivity
disorder (ADHD) and items to allow assessment of childhood conduct disorder.
The NCS strategy of a preliminary screening process was extended to also include
the lifetime use of individual licit and illicit drugs. The goal of this extension
was to reduce any falloff in reporting that might be occasioned by learning
during the course of the interview that positive responses, and not negative
responses to drug questions, tend to be followed by a large battery of additional
questions. Finally, our procedure with the PTSD module differed from both
the NCS and the ECA1 studies. Following an
extensive battery of 41 questions on major and potentially traumatic experiences,
we followed the standard procedure of administering PTSD questions in relation
to the event nominated by respondents as being the worst. However, when, a
diagnostic criterion was not met, participants were presented with a list
of the major PTSD symptoms and asked whether they had ever experienced any
of them in relation to any other event. If a participant responded "yes,"
the event was specified and the PTSD module repeated. This is an efficient
procedure that effectively minimizes the risk of false negatives.
All interviewers held bachelors degrees and most of them had some graduate
education. They were given a total of 7 days of training, 2 days on general
interviewing techniques and procedures, and 5 days on the CIDI. Except for
the initial cohort, this training was followed by the observation of 2 interviews
conducted by experienced interviewers, and by being observed while conducting
interviews of their own. The use of laptop computers assured appropriate skip
patterns and greatly facilitated the reliable administration of the interview.
Our standard practice was face-to-face interviewing in the respondent's home
or in our research offices as the respondent chose. However, telephone interviews
using previously mailed response booklets were employed for those who were
away at university or who had moved elsewhere in the contiguous United States.
Approximately 30% of the interviews were conducted by telephone. There is
abundant evidence that in-person and telephone interviews yield comparable
data.26-28
Analyses were conducted using SPSS 10 (Statistical Products and Service
Solutions 10; SPSS Inc, Chicago, Ill). As noted above, data were weighted
to correct for an underrepresentation of girls with higher socioeconomic status
and to reflect population distributions on gender and ethnicity. The CROSSTABS
and DESCRIPTIVES programs of the SPSS software package were used to compute  2 tests of the significance of prevalence differences across gender
and ethnicity.
RESULTS
Examination of lifetime and past-year prevalence revealed that more
than 60% of the sample met criteria for 1 or more study disorders at some
time during their lives, and 38% did so during the 12 months preceding the
interview (Table 1 and Table 2). Childhood conduct disorder shows
the highest lifetime prevalence, followed by major depressive disorder and
alcohol abuse. It is clear from these results that the consistently observed
gender differences in affective and anxiety disorders are well established
by the transition to adulthood. Females exhibit approximately double the rates
observed for males in both the lifetime and past-year data. This apparent
female disadvantage is somewhat lessened when attention deficit and hyperactivity
disorders are added (38.6% for females vs 27.9% for males), and vanishes altogether
when conduct disorder and antisocial personality disorder are also considered
(46.6% in females vs 45.7% in males). This balance derives from the fact that
boys are 1.75 times more likely to meet criteria for childhood conduct disorder
and more than 2.5 times more likely to qualify for the antisocial personality
diagnosis. In this latter category, 71% of the females and more than 59% of
the males indicated that the behaviors involved were caused by their use of
drugs or alcohol. Thus, not only are females much less likely to meet antisocial
personality diagnostic criteria, those who do are more likely to attribute
their behavior to substance use problems. When drug and alcohol disorders
are also included, the prevalence of all study disorders combined is higher
for males than for females (62.9% vs 58.5%, respectively). However, this difference
is not statistically significant.
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Table 1. Lifetime Prevalence of Psychiatric Disorders by Gender*
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Table 2. Twelve-Month Prevalence of Psychiatric Disorders by Gender*
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In general, 12-month prevalence rates correspond rather closely with
lifetime rates, as might be expected given the youth of the cohort studied
(Table 2). An important point
in connection with these data is the tendency for disorders to be highly recurrent
or persistent. For example, our analyses (not shown) reveal that only 22 %
of 12-month prevalent cases of major depression turn out to be first onsets.
When these cases are excluded from both the lifetime and 12-month prevalence
estimates, the data indicate that 61% of those with a history of major depression
experienced a recurrent or continuing episode of that disorder in the preceding
year. Even in the case of alcohol dependence and marijuana dependence, in
which 59% and 47%, respectively, of the 12-month prevalent cases were new
onsets, approximately half of those with a history of alcohol or marijuana
dependence had a recurrent or continuing episode in the year prior to interview.
Lifetime and 12-month prevalence rates by ethnicity and nativity are
presented in Table 3 and Table 4. In examining these contrasts,
we focus primarily on differences between African American and non-Hispanic
white participants and between US-born and foreign-born participants within
the Cuban and "other Hispanic" subgroups. Although when Axis I lifetime psychiatric
disorders are considered together ("Any psychiatric disorder 1" in Table 3) no statistically significant differences
are observed across ethnicity or nativity, many notable variations are evident
for specific diagnoses. Compared with non-Hispanic white participants, African
Americans are at a substantially lower risk for all study disorders considered
together and for depressive disorder. They are also at dramatically lower
risk with respect to the abuse of or dependence on substances, regardless
of which substance-abuse or dependence category is considered. Among our African
American sample, elevated lifetime prevalence is observed only with respect
to PTSD. A similarly high occurrence of PTSD is found only among US-born "other
Hispanics."
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Table 3. Lifetime Prevalence of Psychiatric Disorders by Ethnicity
and Nativity in 1785 Participants*
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Table 4. Twelve-Month Prevalence of Psychiatric Disorders by Ethnicity
and Nativity in 1785 Participants*
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Comparisons across nativity among Cuban respondents revealed only one
significant difference. Within this subgroup, the foreign-born respondents
reported significantly higher levels of hyperactivity disorder than their
US-born counterparts. In contrast, nativity is associated with a range of
prevalence differences in the "other Hispanic" group. Higher rates were found
among the US-born Hispanics on substance use disorders, conduct disorder,
ADHD, and PTSD.
Because of interest in the possible significance of nativity as a gross
index of acculturation, we also compared prevalence rates observed for US-born
Cubans and US-born "other Hispanics" with those for foreign-born respondents
of the opposite group. Statistically significant contrasts are indicated by
superscript letters attached where relevant to each disorder listed. Except
for PTSD, all of the differences found involved disorders characterized by
externalizing symptoms. Importantly, in every instance, US-born respondents
were shown to be at greater risk than those in the foreign-born comparison
group. The 12-month prevalence data presented in Table 4 present variations across ethnicity and nativity that are
substantially in accord with those found for lifetime prevalence.
Table 5 presents the prevalence
of comorbidity in this community population, where comorbidity is defined
as qualifying for 2 or more diagnoses throughout one's lifetime. The middle
and lower portions of Table 5
report this form of comorbidity when psychiatric and substance use disorders
are considered separately. As shown in the first column of the top portion
of the table, 39% of respondents had never experienced any of the disorders
assessed, about 25% had experienced only 1 disorder, 12% had 2 disorders,
10% had 3, and more than 13% qualified for 4 or more diagnoses. From the second
column, it can be seen that 42% of all lifetime disorders occurred in individuals
whose histories included only that single disorder. In other analyses (not
shown) we found that 62% of 12-month disorders were comorbid.
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Table 5. Comorbidity Among Persons With Lifetime Psychiatric and Substance
Disorders by Ethnicity and Nativity*
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The patterns of comorbidity that are revealed when only psychiatric
disorders are considered (middle portion of Table 5) correspond quite closely with those for all disorders.
However, differences appear in analyses restricted to lifetime substance disorders.
Not only are African Americans dramatically less likely to meet criteria for
substance abuse or dependence (Table 3),
those who do are significantly more likely than others to qualify for only
a single substance use disorder. Somewhat lower rates of substance use disorder
comorbidity are also found among foreign-born "other Hispanics," who, like
the African American group, are comparatively unlikely to have experienced
3 or more substance use disorders.
Comorbidity across substance and psychiatric disorders was also specifically
examined. A total of 154 individuals (8.5% of the sample) met criteria for
at least 1 substance use disorder and 1 psychiatric disorder. In 52.4% of
these instances, the psychiatric disorder was reported to have occurred first;
in 23.5% the substance disorder was first; and in 24%, the onsets of both
types of disorder took place in the same year. It thus seems that psychiatric
disorder is a better predictor of a subsequent substance disorder than is
a substance use disorder a predictor of a subsequent psychiatric disorder.
COMMENT
Despite the youth of this cohort, or perhaps because of it, more than
60% met criteria for 1 or more study disorders during their lives. In the
vast majority of instances, the first onset of disorder occurred during the
middle school and early high school years, and in 58% of the cases, detected
disorders were comorbid. These findings indicate that there is a substantial
presence of psychiatric and substance use disorders in middle and high school
classrooms in South Florida. Thus, it cannot be assumed that study or intervention
participants have no history of having a disorder just because they are young.
This is a point that may not be well understood by many researchers and service
providers.
The substantial level of comorbidity observed here falls well short
of that reported by the NCS that involved participants up to 55 years of age.
This age-associated contrast provides support for the argument that efforts
might be usefully directed toward the primary prevention of secondary disorders.29 Because psychiatric disorders are more likely to
precede the onset of substance use disorders than the reverse, it can be argued
that efforts to prevent the occurrence of drug and alcohol problems should
focus substantial attention on young persons who are experiencing or who have
experienced a psychiatric disorder. Additional analyses (not shown) made clear
that this increased risk for substance abuse or dependence applies to those
with prior episodes of anxiety and/or affective disorders, whether or not
the co-occurrences of conduct, antisocial personality, attention-deficit,
and/or hyperactivity disorders are controlled.
Although expected gender differences in depressive and anxiety disorders
are clearly confirmed in this young adult sample, gender equivalence in total
prevalence was observed without the inclusion of substance diagnoses ("Any
psychiatric disorder 2" in Table 1).
This rather unique finding results from higher rates of hyperactivity disorder,
ADHD, and conduct disorder among males—diagnoses that have not uniformly
been assessed in prior investigations. When substance use disorders were also
considered, the prevalence of "any study disorder" (Table 1) was 62.9% among males compared with 58.5% among females.
The idea that women are at greater risk for mental disorders is not supported
in these results, whether or not substance use disorders are taken into account.
The presence of Hispanics of differing nativity in this study allowed
at least a gross estimation of the significance of acculturation as a risk
or protective factor with respect to psychiatric and substance use disorders.
Results obtained from this same cohort during the early adolescent years revealed
lower rates of substance use among foreign-born compared with US-born participants,8, 30 as well as better mental health.31 Similarly, Vega et al9
found lower rates of psychiatric disorders among Mexican immigrants than among
their US-born counterparts. The findings in this study, with respect to the
"other Hispanic" group but not within the subsample of Cuban heritage, substantially
concur with these prior reports. While a lower prevalence was found among
foreign-born "other Hispanics" for several psychiatric diagnoses, the more
marked differences occurred for the substance use disorders. These latter
contrasts were also observed in comparisons of this group with US-born Cuban
immigrants.
Despite substantial research examining these differences,9, 32
compelling explanations for why greater time spent in the United States is
associated with increased mental health and substance abuse risk8, 10
remain elusive. In this connection, it should be noted that none of the foreign-born
participants in this cohort are recent immigrants, having come to the United
States either before or at the time of entry into middle school. Thus, differences
with their US-born counterparts seem to be persistent in nature. Evidence
bearing on these issues will be presented in subsequent publications.
When psychiatric disorders other than conduct and antisocial personality
disorders were considered together, no significant ethnic differences emerged;
however, important differences in prevalence were observed for individual
diagnoses and when all study disorders were considered together. Consistent
with results from the NCS,2 African Americans
have significantly lower rates of affective disorders, substance use disorders,
and overall lifetime comorbidity than non-Hispanic white participants. However,
contrary to the same study's report of no instances in which either lifetime
or active prevalence was significantly higher among African American than
white participants, we found significantly higher lifetime and 12-month prevalence
of PTSD in the African American subgroup. This finding seems to be in accord
with the results of Breslau et al.33
The limitations of this investigation include those that characterize
prior studies that have derived diagnoses from a single structured interview
that did not involve clinical judgment. Since the data are cross-sectional,
lifetime prevalence estimates rely entirely on retrospective recall. While
the young age of this cohort presumably minimizes recall problems, such problems
remain a concern. Collectively, these measurement concerns require that the
prevalence results reported be viewed as only estimates of the rates at which
symptomatic experiences matching diagnostic criteria occur within the populations
studied.
AUTHOR INFORMATION
Accepted for publication June 26, 2001.
This study was supported by grant R01 DA10772 from the National Institute
on Drug Abuse, Bethesda, Md.
Corresponding author: R. Jay Turner, PhD, Life Course and Health
Research Center, Florida International University, University Park Campus,
Deuxieme Maison (DM 243), Miami, FL 33199 (e-mail: turnerja{at}fiu.edu).
From the Life Course and Health Research Center and the School of Social
Work of the College of Health and Urban Affairs, Florida International University,
Miami.
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ABSTRACT
The Influence of Perceived Risk to Health and Immigration-Related Characteristics on Substance Use Among Latino and Other Immigrants
Ojeda et al.
Am. J. Public Health 2008;98:862-868.
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Associations Between Early-Adolescent Substance Use and Subsequent Young-Adult Substance Use Disorders and Psychiatric Disorders Among a Multiethnic Male Sample in South Florida
Gil et al.
Am. J. Public Health 2004;94:1603-1609.
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Co-Occurring Substance Use and Delinquent Behavior during Early Adolescence: Emerging Relations and Implications for Intervention Strategies
Tubman et al.
Criminal Justice and Behavior 2004;31:463-488.
ABSTRACT
Stress Burden and the Lifetime Incidence of Psychiatric Disorder in Young Adults: Racial and Ethnic Contrasts
Turner and Lloyd
Arch Gen Psychiatry 2004;61:481-488.
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ALCOHOL CONSUMPTION AMONG SCHOOL ADOLESCENTS IN PALMA DE MALLORCA
Tur et al.
Alcohol Alcohol 2003;38:243-248.
ABSTRACT
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Psychiatric Disorders in Youth in Juvenile Detention
Teplin et al.
Arch Gen Psychiatry 2002;59:1133-1143.
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