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Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Alcohol Abuse and Dependence in the United StatesResults From the National Epidemiologic Survey on Alcohol and Related Conditions
Deborah S. Hasin, PhD;
Frederick S. Stinson, PhD;
Elizabeth Ogburn, MS;
Bridget F. Grant, PhD, PhD
Arch Gen Psychiatry. 2007;64(7):830-842.
ABSTRACT
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Context Epidemiologic information is important to inform etiological research and service delivery planning. However, current information on the epidemiology of alcohol use disorders in the United States is lacking.
Objectives To present nationally representative findings on the prevalence, correlates, psychiatric comorbidity, and treatment of DSM-IV alcohol abuse and dependence.
Design, Setting, and Participants Face-to-face interviews with a representative US adult sample (N = 43 093).
Main Outcome Measures Lifetime and 12-month DSM-IV alcohol abuse and dependence.
Results Prevalence of lifetime and 12-month alcohol abuse was 17.8% and 4.7%; prevalence of lifetime and 12-month alcohol dependence was 12.5% and 3.8%. Alcohol dependence was significantly more prevalent among men, whites, Native Americans, younger and unmarried adults, and those with lower incomes. Current alcohol abuse was more prevalent among men, whites, and younger and unmarried individuals while lifetime rates were highest among middle-aged Americans. Significant disability was particularly associated with alcohol dependence. Only 24.1% of those with alcohol dependence were ever treated, slightly less than the treatment rate found 10 years earlier. Strong associations between other substance use disorders and alcohol use disorders (odds ratios, 2.0-18.7) were lower but remained strong and significant (odds ratios, 1.8-7.5) when controlling for other comorbidity. Significant associations between mood, anxiety, and personality disorders and alcohol dependence (odds ratios, 2.1-4.8) were reduced in number and magnitude (odds ratios, 1.5-2.0) when controlling for other comorbidity.
Conclusions Alcohol abuse and dependence remain highly prevalent and disabling. Comorbidity of alcohol dependence with other substance disorders appears due in part to unique factors underlying etiology for each pair of disorders studied while comorbidity of alcohol dependence with mood, anxiety, and personality disorders appears more attributable to factors shared among these other disorders. Persistent low treatment rates given the availability of effective treatments indicate the need for vigorous education efforts for the public and professionals.
INTRODUCTION
Alcohol use disorders (alcohol abuse and dependence) are maladaptive patterns of alcohol consumption manifested by symptoms leading to clinically significant impairment or distress.1 Alcohol abuse and dependence are associated with car crashes,2 domestic violence,3 fetal alcohol syndrome,4 neuropsychological impairment,5 poor medication adherence,6-8 economic costs and lost productivity,9 and psychiatric comorbidity.10-11 The descriptive epidemiology of alcohol use disorders provides important evidence on treatment and prevention needs and informs hypotheses on biological and psychosocial causes of alcohol use disorders. Thus, epidemiologic information must be accurate and up-to-date.
Large-scale US and international surveys conducted in the early 1980s12-14 using DSM-III criteria15 showed current prevalence of alcohol abuse and dependence of 1.9% to 2.1% and 2.8%, lifetime prevalence of 4.4% to 14.0% and 8.8% to 23.0%, and lifetime prevalence of any alcohol use disorder (abuse or dependence) of 12.6% to 27.5%. Using DSM-III-R16 criteria, surveys showed current prevalence of alcohol abuse and dependence of 1.0% to 4.7% and 3.0% to 7.2%, lifetime prevalence of 3.5% to 23.7% and 4.1% to 14.1%, and lifetime prevalence of any alcohol use disorder of 8.5% to 32.8%.17-21 In surveys using DSM-IV criteria,22-25 prevalence of current alcohol abuse and dependence was 1.9% to 4.3% and 3.6% to 4.4%, lifetime prevalence was 4.5% to 13.2% and 3.8% to 13.3%, and lifetime prevalence of any alcohol use disorder was 8.3% to 18.2%. The range of rates over time, location, and diagnostic criteria26-27 leave unclear the relative influence of true variation and methodological differences, although certain risk factors (eg, male sex, younger age) remain consistent throughout. These studies contributed valuable information on alcohol use disorders toward the end of the 20th century, but less is known about the epidemiology of alcohol disorders since then. The National Household Survey on Drug Abuse25 began assessing alcohol disorders in 2000 but does not address lifetime diagnoses, disability, psychiatric comorbidity, or separate information on alcohol abuse and dependence despite differences between abuse and dependence in symptoms, prevalence, and correlates.1, 24
Given the seriousness of alcohol use disorders, current data on the prevalence, correlates, disability, comorbidity, and treatment of alcohol use disorders are needed using a reliable, valid, and uniform data source. Currently, several aspects of the epidemiology of alcohol use disorders are unknown. First, potential health disparities in disadvantaged groups and in birth cohorts now aging (eg, "baby boom" and "generation X" cohorts) require determining the prevalence of alcohol abuse and dependence in these age and race/ethnic groups. Second, accurate information on the distinct comorbidity of alcohol abuse and dependence with other specific mental disorders is important.28-29 These aspects require larger samples than were previously available. Further, the comorbidity of alcohol abuse or dependence with other disorders controlling for the comorbidity of these disorders with each other has not been addressed, which is important information in understanding the unique relationship of alcohol abuse and dependence to other psychiatric disorders. Third, recent US30-31 and international32 surveys deviated from DSM-IV criteria by skipping alcohol dependence criteria if respondents did not endorse alcohol abuse criteria.33-35 This caused about one third of 12-month cases and about 15% of lifetime cases of alcohol dependence (disproportionately women and minorities) to be missed.34 Fourth, determining whether treatment needs that were unmet in the early 1990s are now better served is important.
The present study was designed to provide this knowledge, using data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), sponsored by the National Institute on Alcohol Abuse and Alcoholism.10, 36 The richness, representativeness, and size of the NESARC enabled us to address DSM-IV alcohol abuse and dependence in minorities not previously studied on a national basis, as well as the comorbidity of DSM-IV alcohol abuse and dependence with specific, often rare, psychiatric conditions, disability, and treatment rates among those with alcohol use disorders. Importantly, all symptoms of alcohol abuse and dependence were asked of all drinkers, resulting in complete coverage of both DSM-IV alcohol abuse and dependence.
METHODS
SAMPLE
The 2001-2002 NESARC is based on a US representative sample as described elsewhere.10, 36 The target population included those residing in households and group quarters who were aged 18 years and older. Face-to-face interviews were conducted with 43 093 respondents. The survey response rate was 81%. Blacks, Hispanics, and young adults (ages 18-24 years) were oversampled with data adjusted for oversampling and nonresponse. The weighted data were then adjusted to represent the US civilian population based on the 2000 census. (Table 1 shows the weighted distribution of the NESARC sample.) Field methods included extensive home study and structured in-person training, supervision, and quality control, including random call-backs to respondents to verify data, described in detail elsewhere.10, 36-38
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Table 1. Characteristics of NESARC Respondents
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DSM-IV DIAGNOSTIC INTERVIEW
The diagnostic interview was the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule–DSM-IV Version (AUDADIS-IV).39 This structured interview, designed for lay interviewers, was developed to advance measurement of substance use and mental disorders in large-scale surveys.10, 36 Computer diagnostic programs implemented the DSM-IV criteria for the disorders using AUDADIS-IV data.
ALCOHOL USE DISORDERS
Extensive AUDADIS-IV questions covered DSM-IV criteria for alcohol abuse and dependence. Consistent with DSM-IV, lifetime diagnoses of alcohol abuse required 1 or more of the 4 abuse criteria in the 12-month period preceding the interview or previously. AUDADIS-IV alcohol dependence diagnoses required 3 or more of the 7 DSM-IV dependence criteria in the last 12 months or during any previous 12-month period. For prior diagnoses of alcohol dependence, 3 or more criteria must have occurred within a 1-year period following the DSM-IV clustering criterion. AUDADIS-IV diagnoses of alcohol use disorders incorporate important improvements over other survey instruments, including the Diagnostic Interview Schedule (DIS),40 the University of Michigan Composite International Diagnostic Interview (UM-CIDI),41 and the World Mental Health-CIDI (WMH-CIDI).42 First, to diagnose DSM-IV alcohol dependence, the AUDADIS-IV requires 3 or more criteria within a year in contrast to the DIS and UM-CIDI, which diagnose dependence criteria without requiring syndromal clustering of symptoms. Second, as noted, the WMH-CIDI skipped dependence questions among those with no abuse symptoms. By missing current dependence cases, especially among women and minorities,33-35 the WMH-CIDI underestimates dependence prevalence (NESARC, 3.8% vs National Comorbidity Survey-Replication [NCS-R], 1.3%) and limits the study of comorbidity between alcohol dependence and other psychiatric disorders. In contrast, the NESARC provides complete coverage of DSM-IV alcohol dependence.
The reliability of the AUDADIS-IV alcohol diagnoses is documented in clinical and general population samples43-46 with test-retest reliability ranging from good to excellent ( = 0.70-0.84). Convergent, discriminant, and construct validity of AUDADIS-IV alcohol use disorder criteria and diagnoses were good to excellent,47-51 including in the World Health Organization/National Institutes of Health International Study on Reliability and Validity,52-57 where clinical reappraisals documented good validity of DSM-IV alcohol use disorder diagnoses ( = 0.60-0.76).52, 58 No reliability data exist for the WMH-CIDI42 used in the NCS-R.30-31 Validity coefficients were similar for alcohol disorders in the WMH-CIDI ( = 0.56, 0.70)30 but lower for the DIS ( 0.50).59
MOOD, ANXIETY, AND PERSONALITY DISORDERS
Mood disorders included DSM-IV primary major depressive disorder, bipolar I, bipolar II, and dysthymia. Anxiety disorders included DSM-IV primary panic disorder with and without agoraphobia, social and specific phobias, and generalized anxiety disorder. AUDADIS-IV methods to diagnose these disorders are described in detail in the ARCHIVES10-11 and elsewhere.37-38,60-64 In DSM-IV, "primary" excludes substance-induced disorders or those due to medical conditions; AUDADIS-IV improvements over other measures in making the primary/substance-induced distinction for mood and anxiety disorders are presented elsewhere,10-11,62-64 including the fact that specific AUDADIS-IV questions about the chronological relationship between intoxication or withdrawal and the full psychiatric syndrome implement DSM-IV criteria differentiating primary from substance-induced disorders. Major depressive disorder diagnoses also ruled out bereavement. Personality disorders (PDs), assessed on a lifetime basis, included DSM-IV avoidant, dependent, obsessive-compulsive, paranoid, schizoid, and antisocial personality disorders. DSM-IV PD diagnoses require long-term patterns of social/occupational impairment and exclusion of substance-induced cases; AUDADIS-IV PD diagnoses were made accordingly.60-62
Test-retest reliability for AUDADIS-IV mood, anxiety, and personality diagnoses in general population and clinical settings was fair to good ( =0.40-0.62).44-46 Test-retest reliabilities of AUDADIS-IV personality disorders (not measured in prior surveys) compare favorably with those in patient samples using semistructured personality interviews.65 Convergent validity was good to excellent for all affective and anxiety diagnoses, and selected diagnoses showed good agreement ( = 0.64-0.68) with psychiatrist reappraisals,11, 46, 58 similar to that of the NCS-R WMH-CIDI ( = 0.54)30 and better than the DIS ( = 0.20).66-67 Test-retest reliability data do not exist for the DIS in general population samples or for the NCS-R WMH-CIDI.
DISABILITY AND IMPAIRMENT
Disability among respondents was determined with the Short Form 12, version 2 (SF-12v2).68 In contrast to other measures of functioning that incorporate information on premature mortality (disability-adjusted life years), the SF-12v2 is a reliable and valid measure of current impairment in psychosocial functioning widely used in population surveys.68 The SF-12v2 scales included mental health, social functioning (limitations due to emotional problems), role emotional functioning (role impairment due to emotional problems), and mental component summary (MCS). Each SF-12v2 norm-based disability score is a continuous variable with mean of 50 in the general population, a standard deviation of ± 10, and a range of 0 to 100. Lower scores indicate more disability.
STATISTICAL ANALYSES
Weighted means, frequencies, and cross-tabulations were computed. Adjusted odds ratios (ORs) derived from multiple logistic regressions indicated associations between alcohol abuse or dependence and sociodemographic variables. Associations of alcohol use disorders with psychiatric comorbidity were calculated 2 ways. The first included control for sociodemographic characteristics comparable with other reports on comorbidity. The second way further controlled for all other substance use and psychiatric disorders. This analysis addresses the fact that tests of association controlling only sociodemographic characteristics do not yield information on the unique relationship of other disorders (that themselves have considerable comorbidity) to alcohol abuse and dependence. Analyses that control for other comorbidity test the hypothesis that an alcohol diagnosis is associated with the pure (noncomorbid) form of the other disorder.69
The relationship of 12-month alcohol abuse and dependence to disability as measured by the SF-12v2 disability scores was determined using multiple linear regression analyses controlling for sociodemographic characteristics and all other substance use, mood, anxiety, and personality disorders assessed in the NESARC. Hazard rates, reflecting lifetime alcohol abuse and dependence risk at specific ages among the population at risk at those ages, were calculated using standard life table methods.70 Hazard rate curves were statistically smoothed by using rolling averages of 5-year age groups, a standard methodology. Standard errors and 99% confidence intervals were estimated using SUDAAN,71 which adjusts for characteristics of complex sample surveys such as the NESARC.
RESULTS
PREVALENCE AND SOCIODEMOGRAPHIC CORRELATES OF DSM-IV ALCOHOL ABUSE AND DEPENDENCE
The 12-month prevalences of DSM-IV alcohol abuse and dependence (Table 2) were 4.7% and 3.8%; the 12-month prevalence of any alcohol use disorder was 8.5%. The lifetime prevalences of DSM-IV alcohol abuse and dependence were 17.8% and 12.5%, respectively; the total lifetime prevalence of any alcohol use disorder was 30.3%. Table 3 shows the risks of 12-month and lifetime abuse and dependence in population subgroups via adjusted ORs and 99% confidence intervals.
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Table 2. Prevalences of 12-Month and Lifetime DSM-IV Alcohol Use Disorders by Sociodemographic Characteristics
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Table 3. Adjusted Odds Ratios of 12-Month and Lifetime DSM-IV Alcohol Use Disorders by Sociodemographic Characteristics
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For 12-month disorders, odds of alcohol abuse were greater among men; among whites compared with blacks, Asians, and Hispanics; and among respondents who were younger and unmarried. The odds of 12-month dependence were lower in the South than in the West and among Asians, blacks, and Hispanics than whites. The odds were also higher among men, younger and unmarried adults, and those in the lowest income group.
For lifetime abuse and dependence, the odds were higher among men and lower among blacks, Asians, and Hispanics compared with whites. The odds of lifetime alcohol abuse were greater among respondents aged 30 to 64 years and lower among never-married adults, those with a high school education, and lower income. The odds of lifetime dependence were greater in the youngest age groups, unmarried respondents, Native Americans, and those with lower incomes; odds were lower in the Northeast and South than in the West.
ASSOCIATIONS BETWEEN DSM-IV ALCOHOL USE DISORDERS AND OTHER PSYCHIATRIC DISORDERS, CONTROLLING FOR SOCIODEMOGRAPHIC CHARACTERISTICS
Comorbidity between DSM-IV alcohol abuse and dependence and other psychiatric disorders adjusted for sociodemographic characteristics is outlined in Table 4 for 12-month and Table 5 for lifetime disorders. Twelve-month alcohol abuse was significantly associated with other 12-month substance use disorders except drug dependence but unrelated to 12-month psychiatric disorders except antisocial PD. In contrast, 12-month alcohol dependence was strongly and significantly associated with all 12-month substance use and psychiatric disorders. Lifetime alcohol dependence comorbidity followed a similar pattern.
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Table 4. Adjusted Odds Ratios of 12-Month DSM-IV Alcohol Use Disorders and Other Psychiatric Disorders Controlling for Sociodemographic Characteristics and Comorbid Psychiatric Disorders
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Table 5. Adjusted Odds Ratios of Lifetime DSM-IV Alcohol Use Disorders and Other Psychiatric Disorders Controlling for Sociodemographic Characteristics and Comorbid Psychiatric Disorders
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ASSOCIATIONS BETWEEN DSM-IV ALCOHOL USE DISORDERS AND OTHER PSYCHIATRIC DISORDERS, CONTROLLING FOR SOCIODEMOGRAPHIC CHARACTERISTICS AND OTHER COMORBIDITY
The associations of 12-month and lifetime DSM-IV alcohol abuse and dependence with other substance use and psychiatric disorders, controlling for sociodemographic characteristics and psychiatric comorbidity, are outlined in Table 4 and Table 5. Odds ratios were reduced when other comorbidity was controlled. Twelve-month alcohol abuse remained strongly and significantly associated with substance use disorders (OR 1.8) but not with other Axis I disorders (and was negatively associated with schizoid PD). A similar pattern was observed for lifetime abuse with an additional negative association with bipolar I disorder. Twelve-month alcohol dependence remained strongly associated with substance use disorders (ORs = 3.4-7.5) and bipolar disorders but with lower ORs (1.9, 2.0) and was significantly associated with only 2 Axis II disorders: histrionic and antisocial PD. Lifetime DSM-IV alcohol abuse followed a similar pattern of associations when comorbidity was controlled. Lifetime DSM-IV alcohol dependence remained positively although less strongly associated with substance use disorders; most mood and anxiety disorders; and paranoid, histrionic, and antisocial PDs.
ONSET AND COURSE OF DSM-IV ALCOHOL USE DISORDERS
Mean ages at onset of alcohol abuse and dependence were 22.5 and 21.9 years, respectively. Hazard rates for onsets of both disorders (Figure) peaked at age 19 years, decreasing thereafter. Mean durations of longest episodes of alcohol abuse and dependence were 2.7 and 3.7 years. Of respondents with lifetime abuse or dependence, 72.0% had one episode; 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). Mean duration of abuse episodes among respondents with a single episode (2.7 years) vs multiple episodes (2.4 years) did not differ significantly.
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Figure. Hazard rates for age at onset of DSM-IV alcohol abuse and alcohol dependence.
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DISABILITY ASSOCIATED WITH DSM-IV ALCOHOL ABUSE AND DEPENDENCE
Mean (SE) SF-12v2 scores for those with current (12-month) alcohol abuse ranged from 48.8 (0.23) to 49.8 (0.26); corresponding scores for those with 12-month alcohol dependence ranged from 47.3 (0.37) to 48.2 (0.39) (Table 6). Adjusting for sociodemographic characteristics and other Axis I and II disorders, alcohol abuse was associated with lower social functioning (b = –0.59; P<.05) and role emotional functioning (b = –0.96; P<.003) while alcohol dependence was highly and significantly associated with lower MCS (b = –2.52; P<.001), mental health (b = –1.39; P<.001), social functioning (b = –2.06; P<.001), and role emotional functioning (b = –2.07; P<.001). Disability increased steadily and significantly with alcohol dependence severity (adjusted for sociodemographic characteristics and other Axis I and II disorders, b = –0.92 [SE = 0.1], P<.001). The lowest quartile of MCS scores among respondents with alcohol dependence was 43.6 or less. For comparative purposes, mean (SE) MCS scores for respondents with 12-month drug abuse, drug dependence, any anxiety disorder, any mood disorder, and any (lifetime) personality disorder were 48.7 (0.54), 41.9 (1.15), 41.7 (0.27), 46.5 (0.22), and 47.3 (0.17), respectively. Thus, respondents with alcohol abuse manifested less disability than those with drug, anxiety, mood, or personality disorders. On average, respondents with alcohol dependence manifested less disability than those with drug dependence and anxiety disorders, but their disability was comparable with that among respondents who had drug abuse, mood, and personality disorders.
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Table 6. Mean Disability Scores (Short Form 12, version 2) and 12-Month Alcohol Use Disorders
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TREATMENT FOR DSM-IV ALCOHOL USE DISORDERS
Of those with lifetime alcohol dependence, only 24.1% ever received treatment while of those with 12-month alcohol dependence, only 12.1% received alcohol treatment in the past year. Among those with lifetime and 12-month alcohol abuse, 7.0% and 3.1% received any alcohol treatment, respectively. These treatment rates are slightly lower than treatment rates 10 years earlier (dependence: 23.5% lifetime and 13.8% 12-month; abuse: 9.2% lifetime and 4.4% 12-month).24 In the NESARC, the mean age of respondents' first treatment for dependence was 29.8 years, an 8-year mean lag between onset and treatment. The mean age of first treatment for abuse was 32.1 years, a 10-year mean lag between onset and treatment.
Among those with 12-month alcohol dependence, 7.4% received help from 12-step (self-help) groups; 10.0% from any health professional other than 12-step groups, employee assistance programs, or clergy; and 6.7% from physicians or other health professionals; with other treatment sources less frequent (Table 7). Of those with 12-month alcohol abuse, 2.0% received help from 12-step groups; remaining percentages ranged from 0.0% (halfway houses) to 1.9% (any professional other than 12-step groups, employee assistance programs, or clergy). Respondents with lifetime alcohol use disorders showed similar ranking of treatment patterns regarding prevalence by setting. Excluding 12-step programs, employee assistance programs, and clergy, lifetime professional treatment rates were 4.5% among respondents with alcohol abuse and 20.1% among respondents with alcohol dependence.
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Table 7. Alcohol Treatment and Help-Seeking Settings Among Respondents With 12-Month and Lifetime DSM-IV Alcohol Use Disorders
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Among respondents with 12-month alcohol use disorders, few characteristics significantly (P<.05) predicted treatment. For 12-month alcohol dependence, the lowest income category predicted treatment (OR = 2.8). For 12-month abuse, compared with married and cohabiting respondents, those widowed, separated, or divorced (OR = 3.5) were more likely to receive treatment as were those with less than high school education (OR = 4.0). For lifetime abuse and dependence, treatment likelihood increased among men, unmarried respondents, and those with lower education and incomes (ORs = 1.5-2.3).
COMMENT
In the United States in 2001-2002, 8.5% of adults experienced alcohol use disorders in the prior 12 months (4.7% abuse, 3.8% dependence) while 30.3% experienced alcohol use disorders during their lifetimes (17.8% abuse, 12.5% dependence). The duration of alcohol disorders was often chronic with a mean of nearly 4 years for alcohol dependence. The disorders were associated with significant disability. Thus, alcohol use disorders continue to present a widespread and serious personal and public health problem in the United States.
Consistent with previous studies17, 20, 22-23,25 and recent reviews,72-73 men were at greater risk of alcohol use disorders than women. Younger cohorts also showed higher risk of alcohol dependence and current alcohol abuse. This could indicate a true cohort effect or, alternatively, an undercount among older cohorts due to differential mortality or poor recall of remote events. Longitudinal studies are needed to address this issue. In contrast, the highest risk for lifetime alcohol abuse was in the baby boom and generation X cohorts (aged 30-64 years). This is the first time such an age distribution in an alcohol use disorder has been identified in the United States, although it is consistent with the new age distribution found in the NESARC for major depressive disorder.11 Investigation of the reasons for this changed age pattern is warranted.
Due to its size, the NESARC provides more precise information on the risk for alcohol disorders by ethnic group than any other source. The findings indicate higher risk for lifetime alcohol dependence among Native Americans, which is consistent with local studies of Native Americans showing high rates of alcohol-related morbidity and mortality.74-77 The specific risk among Native Americans for alcohol dependence but not abuse warrants further research.
The NESARC is consistent with earlier studies showing African Americans and Asians at lower risk than whites for alcohol abuse and dependence.23 Among Asians, genetic factors affecting alcohol metabolism likely influence the rates.78-80 Lower socioeconomic status generally increases poor health indicators81 and the mean socioeconomic level of African Americans is lower than many other US groups. Therefore, determining the protective factors decreasing African American risk for alcohol use disorders is of interest, both to better understand the overall etiology of alcohol disorders and to develop improved prevention and intervention for blacks who do develop alcohol abuse or dependence.
NESARC findings of lower risk for alcohol abuse and dependence among Hispanics contribute new information. The NESARC size, oversampling for Hispanics (20% of the sample), and cultural sensitivity of the survey82 provide highly accurate findings on Hispanics. Further analyses are needed to understand potential protective factors in these groups (eg, family cohesiveness, social norms).82-84 Such work should distinguish between Hispanic groups since these may differ. Note that lower rates among disadvantaged minority groups do not reduce the importance of providing treatment to those with alcohol use disorders when they occur.
While alcohol abuse showed comorbidity with drug abuse, nicotine dependence, and antisocial PD, associations with other disorders, even when significant, were weak (OR 1.3). Consistent with earlier reports,17-25 alcohol dependence showed strong, significant associations with all other substance and psychiatric disorders, controlling only for sociodemographic characteristics. This indicates that alcohol dependence remains highly comorbid with other disorders and that better understanding of the causes and treatment implications of this comorbidity would serve important public health functions. The results also underscore the importance of examining alcohol abuse and dependence separately.
To also understand the unique relationships of other disorders to alcohol dependence, we additionally determined the associations controlling for all remaining disorders measured in the study. Associations with drug and nicotine use disorders were reduced but remained strong and significant. The drop in magnitude suggests common causal factors underlying alcohol and other substance use disorders (consistent with family,69 twin,85-86 and genetic association studies87-88). However, remaining associations of alcohol dependence with other substance disorders after controlling for comorbidity suggest unique factors leading to the disorder-specific associations, for example, that the specific factors underlying associations between alcohol and nicotine dependence are not necessarily the same as the specific factors underlying associations between alcohol and illicit drug use disorders. This finding, also consistent with twin studies,85-86 suggests continued investigation of both common and specific factors leading to associations between alcohol and other substance use disorders.
With control for additional comorbidity, significant associations remained only between alcohol dependence and bipolar I, bipolar II, specific phobia, and histrionic and antisocial PDs, and these were considerably reduced. Thus, while some unique disorder-specific associations were found, much of the association of alcohol dependence with other affective, anxiety, and PDs appears due to factors common to these other disorders.
The mean length and number of alcohol dependence episodes (72% reporting 1, the remainder reporting a mean of about 5), indicate 2 important points: first, alcohol dependence is highly chronic, and second, recovery is possible (addressed in detail elsewhere89-90). The recovery rates provide an important empirical counterpoint to the belief that alcohol disorders are always lifelong with efforts at recovery always unsuccessful.
All measures of current disability from the SF-12v2 scales were strongly associated with DSM-IV alcohol dependence, controlling for sociodemographic characteristics and comorbidity, and were similar to impairment levels for drug abuse, mood disorders, and PDs. Further, as severity of alcohol dependence increased, impairment approached the more severe levels associated with other disorders. When untreated, impaired functioning may diminish life chances and increase stressful life conditions even after alcohol dependence remits, increasing the subsequent risk for other psychiatric disorders such as major depression.91 The NESARC findings on disability underscore the seriousness of DSM-IV alcohol dependence, which largely occurs among those who never receive treatment. In fact, among those with lifetime alcohol dependence, less disability was found among treated compared with untreated respondents (mean [SE] MCS scores 48.1 [0.40] and 44.7 [0.78], respectively, P<.02). Further investigation of the determinants of disability among those with alcohol use disorders is warranted.
Compared with 1991-1992, treatment rates for alcohol use disorders in 2001-2002 reveal a disappointing lack of progress. Most excessive drinkers are insured and have regular medical contacts,92 so lack of health insurance does not account for this problem. The lack of progress on treatment for alcohol disorders differs sharply from improvement in treatment rates for major depression in recent years.93 In identifying ways to improve treatment rates for alcohol disorders, depression may offer instructive points to consider. These include availability of multiple medications and behavioral treatments with reasonable efficacy, few adverse effects and simple regimens, and rapid screening measures for routine practice.94-95 Additional points include a National Institute of Mental Health campaign to destigmatize depression and educate the public and professionals about recognition and treatment96 and vigorous pharmaceutical promotion of antidepressants to professionals and the public.93
In contrast, alcohol disorders remain highly stigmatized,97-98 more so than mental illness.99 Medical attention to alcohol problems has declined100-101 for many reasons, including clinician lack of knowledge,102 uncertainty that screening is warranted,103 insufficient organizational support,104 and low expectations of results.105-106 Individuals with alcohol disorders also express lack of confidence in alcoholism treatment and stigmatization as reasons for not seeking treatment.107
Evidence on the effectiveness of alcohol treatment is inconsistent with these negative beliefs. Published NESARC findings indicate that treatment and participation in 12-step groups significantly and substantially increased the likelihood of recovery from alcohol dependence89 with other characteristics influencing recovery in more complex ways.90 Many randomized trials demonstrate the efficacy of brief drinking reduction interventions in medical or primary care settings for those whose problems are not yet chronic and severe.108-112 For more severe alcohol disorders, reasonably effective medications include naltrexone113-115 and possibly acamprosate116-119 while evidence-based manualized behavioral treatments include 12-step facilitation,120-121 motivational interviewing,122 cognitive behavioral therapy,123 and a combination of these.124 A multisite randomized trial recently added evidence on the effectiveness of naltrexone and behavioral treatment, including medical management.125 These interventions have efficacy comparable with many routine treatments for other diseases.126 The NIAAA clinician's guide127 provides brief, clear instructions on screening and intervention for alcohol problems, and training packages for these procedures are available.128
Thus, numerous factors identified as important in improving treatment rates for major depression93-95 also exist for alcohol. What is lacking is a major effort to change public and professional attitudes toward treatment. In the absence of vigorous pharmaceutical marketing, an intensive government program and active work by other nonprofit agencies is urgently needed to educate the public and professionals about the signs and risks of alcohol dependence, to destigmatize the illness, and to promote understanding of the benefits of intervention.
Potential study limitations are noted. Similar to all prior epidemiologic studies, lifetime comorbidity associations may be subject to recall bias and pseudocomorbidity129 (ie, estimated lifetime associations may be biased due to variation of the association by age at onset of the comorbid disorders). However, these issues are not relevant to comorbidity estimates of 12-month disorders. Most other psychiatric epidemiology studies have focused on lifetime comorbidity associations because samples were too small for stable 12-month comorbidity estimates.14, 19 However, the large sample size of the NESARC permitted comorbidity analyses for 12-month disorders at the same level of detail as lifetime disorders. These analyses indicated that the direction and magnitude of the comorbidity associations were very similar for 12-month and lifetime disorders, suggesting that any biases in the NESARC lifetime comorbidity estimates may not be strong enough for concern. Another potential limitation includes the cross-sectional design. Accordingly, when data from a 3-year follow-up of NESARC participants become available, they will offer a rich source of information to further investigate the relationships found and their stability in the general population.
In summary, the NESARC has shown that DSM-IV alcohol abuse and dependence are highly prevalent, disabling disorders that go largely untreated in the United States. The study identified population subgroups at particular risk and generated many findings that can lead to further, hypothesis-driven investigation. Further, the study showed that at this point, a call to action appears indicated to educate and update the public and policy-makers about alcohol use disorders, to destigmatize the disorders, and to encourage help-seeking among those who cannot stop drinking despite considerable harm to themselves and others.
AUTHOR INFORMATION
Correspondence: Bridget F. Grant, PhD, PhD, Laboratory of Epidemiology and Biometry, Room 3077, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, MS 9304, 5635 Fishers Ln, Bethesda, MD 20892-9304 (bgrant{at}willco.niaaa.nih.gov).
Submitted for Publication: May 10, 2006; final revision received September 26, 2006; accepted October 1, 2006.
Financial Disclosure: None reported.
Funding/Support: The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) is funded by the National Institute on Alcohol Abuse and Alcoholism with supplemental support from the National Institute on Drug Abuse. This research was supported in part by the Intramural Program of the National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. Support is also acknowledged from K05 AA 014223 and the New York State Psychiatric Institute (D.S.H.).
Disclaimer: The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations or agencies or the US government.
Author Affiliations: Mailman School of Public Health (Dr Hasin and Ms Ogburn) and College of Physicians and Surgeons (Dr Hasin), Columbia University, New York, New York; New York State Psychiatric Institute, New York (Dr Hasin and Ms Ogburn); and Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland (Drs Stinson and Grant).
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33. Grant BF, Compton WM, Crowley TJ, Hasin DS, Helzer JE, Li T-K, Rounsaville BJ, Volkow ND, Woody GE. Errors in assessing DSM-IV substance use disorders [letter]. Arch Gen Psychiatry. 2007;64(3):379-380.
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38. Grant BF, Hasin DS, Stinson FS, Dawson DA, Goldstein RB, Smith SM, Huang B, Saha TD. The epidemiology of DSM-IV panic disorder and agoraphobia in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67(3):363-374.
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43. Chatterji S, Saunders JB, Vrasti R, Grant BF, Hasin D, Mager D. Reliability of the alcohol and drug modules of the Alcohol Use Disorder and Associated Disabilities Interview Schedule—Alcohol/Drug-Revised (AUDADIS-ADR): an international comparison. Drug Alcohol Depend. 1997;47(3):171-185.
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44. Grant BF, Dawson DA, Stinson FS, Chou PS, Kay W, Pickering R. The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample. Drug Alcohol Depend. 2003;71(1):7-16.
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46. Hasin D, Carpenter KM, McCloud S, Smith M, Grant BF. The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability of alcohol and drug modules in a clinical sample. Drug Alcohol Depend. 1997;44(2-3):133-141.
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52. Cottler LB, Grant BF, Blaine J, Mavreas V, Pull C, Hasin D, Compton WM, Rubio-Stipec M, Mager D. Concordance of DSM-IV alcohol and drug use disorder criteria and diagnoses as measured by AUDADIS-ADR, CIDI and SCAN. Drug Alcohol Depend. 1997;47(3):195-205.
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53. Hasin DS, Grant BF, Cottler L, Blaine J, Towle L, Ustun B, Sartorius N. Nosological comparisons of alcohol and drug diagnoses: a multisite, multi-instrument international study. Drug Alcohol Depend. 1997;47(3):217-226.
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55. Pull CB, Saunders JB, Mavreas V, Cottler LB, Grant BF, Hasin DS, Blaine J, Mager D, Ustun BT. Concordance between ICD-10 alcohol and drug use disorder criteria and diagnoses as measured by the AUDADIS-ADR, CIDI and SCAN: results of a cross-national study. Drug Alcohol Depend. 1997;47(3):207-216.
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57. Vrasti R, Grant BF, Chatterji S, Ustun BT, Mager T, Olteanu I, Badoi M. Reliability of the Romanian version of the alcohol module of the WHO Alcohol Use Disorder and Associated Disabilities Interview Schedule–Alcohol/Drug-Revised. Eur Addict Res. 1998;4(4):144-149.
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60. Grant BF, Hasin DS, Stinson FS, Dawson DA, Chou SP, Ruan WJ, Pickering RP. Prevalence, correlates, and disability of personality disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2004;65(7):948-958.
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91. Hasin DS, Grant BF. Major depression in 6050 former drinkers: association with past alcohol dependence. Arch Gen Psychiatry. 2002;59(9):794-800.
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