Olanzapine-induced Concurrent Tardive Dystonia and Tardive Dyskinesia in Schizophrenia with Intellectual Disability:A Case Report

Tardive dystonia and tardive dyskinesia (TDs) are rare extrapyramidal side effects that develop after long-term use of antipsychotics, but they are different syndromes and rarely occur at the same time. Olanzapine is an atypical antipsychotic drug associated with a low risk of extrapyramidal side effects in schizophrenia, but its associations with tardive movements are not clear. We present a case of a 19-year-old Asian female patient with schizophrenia and intellectual disabilities who developed concurrent TDs after long-term use of olanzapine. At her 10-month follow-up examination, her concurrent TDs had been treated successfully with clozapine. This case demonstrates that although the use of olanzapine to treat psychosis and behavioral disturbances is increasing due to its high efficacy and low rate of extrapyramidal side effects, concurrent TDs should be carefully assessed after long-term use of this antipsychotic, especially in patients with schizophrenia and intellectual disabilities. Clozapine, by preventing or reversing the debilitating consequences of concurrent TDs, may be an effective treatment for these patients.

Economic Evaluation of Add-on Levetiracetam for the Treatment of Refractory Partial Epilepsy in Korea

OBJECTIVE: This study estimated the expected cost-effectiveness ratio expressed as the incremental cost per seizure-free day (SFD) gained and the incremental cost per quality adjusted life year (QALY) gained when using levetiracetam (LEV) as add-on therapy from a third-party payer perspective. METHODS: A 1-year dose-escalation decision-tree model comparing LEV plus standard therapy (ST) with ST alone was designed to combine transition probabilities, costs and outcomes. The short-term outcomes and probabilities were derived from a prospective, open-label clinical trial with 100 Korean adults with refractory partial epilepsy. All data for the direct medical costs were derived from Korean cost data extracted from reports published by the National Health Insurance Corporation. RESULTS: The average gain in SFDs attributed to LEV add-on was 18.3 days per patient per year and the incremental cost-effectiveness ratios (ICERs) for LEV add-on were US$ 44 per SFD per patient and US$ 11,084 per QALY gained. All sensitivity analyses showed that the model was robust to the assumptions made. CONCLUSION: The economic evaluation indicates that, given a wide range of assumptions, the increased cost of treating patients having refractory partial epilepsy with LEV may be partially offset by a reduction in other direct medical costs. This reduction is a consequence of an increase in the number of SFDs and improved quality of life.

Rate and Predictors of Mortality in Elderly Nursing Home Residents with Dementia:5-Year Follow-Up Study

OBJECTIVES:To investigate mortality rates and predictors of mortality in dementia patients (prevalence cohort) resident at institution. METHODS:We followed up a dementia cohort for 5 years. A total of 273 subjects with dementia were longitudinally assessed at baseline, 6 months and 12 months and then checked whether alive or dead every 1 year for 5 years. Their mortality was compared with sociodemographic and clinical variables using Cochran-Mantel-Haenszel test and independent sample t-test. Survival time quartiles were used to describe the time until when 25%, 50%, and 75% of patients died. Kaplan Meier log-rank tests were used for testing the equality of survival among groups when identifying some disruptive agitated behaviors as mortality predictors. Relative risk (RR) with 95% confidence intervals were calculated by the Cox regression analysis. RESULTS:In this study, overall 5-year mortality rate was 63.0% (12.6% per year). Median survival after baseline evaluation was 2.85 years, whereas median survival after institutionalization was 6.42 years. Log-rank tests revealed that some disruptive behaviors (i.e., Cagras syndrome, screaming, trying to get to a different place, intentional falling) were significantly higher in the deceased group. Mortality in subjects with dementia depended on old age {over 85, relative risk (RR):1.04;95% confidence interval (CI):1.02-1.06}, male gender (RR:2.04;CI:1.28-3.25), lower MMSE-K score (RR:1.03;CI:1.00-1.06). CONCLUSION:We expect that this study may provide basic health information for health policy making in institutional care approaches in Korea

Economic and Clinical Benefits of Galantamine in the Treatment of Mild to Moderate Alzheimer's Disease in a Korean Population: A 52-Week Prospective Study

To evaluate the impact of galantamine treatment on the function, caregiver time, and resource used in the treatment of patients with mild to moderate Alzheimer's disease (AD), costs and outcomes were evaluated during a 52-week prospective, randomized, double-blind, community-controlled trial of galantamine. Patients received either galantamine treatment (n=72) or no treatment (n=66). The analysis was performed from a societal perspective. Galantamine treatment reduced time spent caring for the patients and maintained improved functional capacity, whereas, when no treatments were given, a great increase in caregiver time and progressive functional deteriorations were observed. Saved caregiver time was equivalent to 113 working days per year. After 52 weeks, mean total annual costs per patient were 14,735,000 Korea Won (KRW) (USD 12,315) for patients with galantamine treatment and 25,325,000 KRW (USD 21,166) for patients without treatment. Adjusted annual cost saving of galantamine treatment was 6,428,000 KRW (USD 5,372) when compared to no treatment (p=0.0089). Galantamine had a beneficial effect not only to slow functional decline in patients with mild to moderate AD, but also to save a substantial amount of costs, closely related to reduction in caregiver burden and decrease in caregiver time.

Effect of Galantamine on Caregiver Time and Activities of Daily Living in Mild to Moderate Alzheimer's Disease: A 1-Year Prospective Study

OBJECTIVE: This study aims to investigate the effect of galantamine on caregiver time and activities of daily living(ADLs) in patients with mild to moderate Alzheimer's disease(AD) in a Korean population. DESIGN: Quasi-experimental study: A rndomized, double-blind, parallel-group clinical trial and a naturalistic longitudinal community study METHOD: For this 1-year prospective study, 138 patients residing in the community were recruited(baseline MMSE score of. 10-22). The two groups were composed of 72 patients treated with galantamine and 66 patients selected as the control group from an untreated community cohort of AD patients. The primary efficacy outcome was the caregiver time and the secondary efficacy measure was the Korean version of the Disability Assessment for Dementia(DAD-K) scale. RESULTS: The results of a mixed model analyses demonstrated reduced caregiver time and improved ADLs in galantamine group relative to baseline and compared with the community control group in this 1-year prospective study. Significant improvement in galantamine group observed in the DAD scores demonstrated beneficial effects of galantamine on delaying functional deterioration in patients with mild to moderate AD. Difference in caregiver time between two groups was equivalent to additional 9.5 working days per month or 113 working days per year. CONCLUSION: Treatment with Galantamine is associated with a significantly slower decline in basic and instrumental ADLs in patients with mild to moderated AD. These benefits on functional capacity in patients with AD treated with galantamine were associated with less caregiver time, lower caregiver burden and higher economic benefits.

Comparison between Alcohol Dependence and Alzheimer Disease in the Elderly Patients using the Cognitive Assessment Reference Diagnoses System

BACKGROUND: Alcohol dependence and Alzheimer's disease induce cognitive dysfunction in common. However, the cognitive dysfunction from alcohol dementia can be improved with appropriate treatment while that from Alzhimer's disease is usually irreversible and progressive. Nevertheless, the discrete diagnosis for the cause is delicate or sometimes impossible in those patients showing both characteristics of alcohol dementia and Alzhimer's disease. Thus, we investigated the feasibility of the computerized comprehensive neuropsychological test, Cognitive Assessment and Reference Diagnoses System(CARDS), to differentiate the diagnoses between alcohol dementia and Alzhiemr's disease in their early stages. METHODS:32 elderly subjects with cognitive dysfunction were recruited. They are divided by two groups; 16 subjects with alcohol dependence and 16 subjects without alcohol dependence(as early Alzhiemr's disease) We assessed the cognitive dysfunctions of each group using CARDS. The subscales of the CARDS include; (1) Amnesia, (2) Aphasia, (3) Apraxia, (4) Dysexecution, (5) Attention/Calculation. RESULTS: Alcohol dependence group showed lower mean score in amnesia subscale, but showed higher mean scores in apraxia and dysexcution subscales than early Alzheimer group. And both groups didn't show significant differences of mean scores in agonisa, aphagia, and attention/calculation subscale. CONCLUSION: In summary, this study shows that the elderly patients with alcohol dependence have cognitive deficits mainly in the amnesia domain of CARDS assessment, whereas early Alzhiemr's disease patients show equal or worse cognitive function in other domains except amnesia. Thus, we suggest that CARDS will be helpful to differentiate alcoholic dementia and Alzhiemr's disease in their early stages.

Drug Therapy for Alzheimer's Disease

Alzheimer's disease (AD) is the most common cause of dementia in the elderly. AD afflicts 0.3 to 0.5 million people in Korea, and the number is projected to increase to 2 million by the year of 2050. This article provides a brief overview of the most popular drug therapies in the treatment of AD including cholinesterase inhibitors (AchEIs) (donepezil, galantamine, rivastigmine), NMDA receptor antagonist (memantine), acetyl-l-carnitine, antioxidant vitamins, and Ginko biloba. Based on a review of relevant papers in the literature, this article presents pharmacological and clinical safety profiles of these agents and prescribing tips as well as a final summary on the effectiveness, safety, and alerts for clinicians. AchEIs as well as memantine will continue to play an important role in the treatment armamentarium for AD, even though newer strategies are being explored. There is not enough evidence supporting the continuous use of other drugs such as acetyl-l-carnitine, antioxidant vitamins, and Ginko biloba for the treatment of AD.

Mortality Rates and Risk Factors in Community Based Dementia Patients

OBJECTIVES: The aim of this study was to investigate mortality rates and risk factors in dementia patients in a rural cohort. METHODS: A total of 114 subjects with clinically diagnosed dementia were followed up for eight years from 1997 to 2005. Their mortality was compared with sociodemographic and clinical variables using the Cox proportional hazards models after adjusting age, sex, and education. RESULTS: During follow-up, the mortality rate of subjects was 80.2% and the mean (SD) duration of survival from at diagnosis to death was 4 years. Mortality in subjects with dementia depended on old age (relative risk [RR] : 1.05 ; 95% confidence interval [CI] : 1.01-1.08), male (RR : 1.61 ; CI : 1.00-2.59), low Clinical Dementia Rating scale (RR : 1.54 ; CI : 1.14-2.10), low Activities of Daily Living (RR : 0.72 ; CI : 0.59-0.89), low Instrumental Activities of Daily Living (RR : 0.83 ; CI : 0.75-0.92), no physical activity (RR : 0.44 ; CI : 0.28-0.70), smoking (RR : 1.74 ; CI : 1.05-2.89). CONCLUSION: Mortality in dementia depended on age, sex, CDR, ADL, IADL, physical activity, smoking. These findings have important implications that contribute to make the disease management of dementia patients.

A Community Study of Depression in Old Age

BACKGROUNDS: Depression in old age has significant negative impact on physical health and social activities, which may greatly burden a society with increased costs of use of health care resources and may seriously hamper individual's quality of life. This study aimed to identify the prevalence and risk factors of depression in older community population. METHOD: By the random sampling, study population(n=1,300) was selected out of total population of the elderly aged 65 years or older in Asan city(N=14,977). Two-phase community survey method was used; the Korean version of the Geriatric Mental State Schedule(GMS-K) was used as a screening instrument to define caseness group by trained interviewers, while board-certified psychiatrists confirmed clinical diagnoses according to the DSM-IV criteria by face-to-face interview of subjects for the Stage 2 study. RESULTS: Of 1,300 subjects, 1,246 elderly completed the stage 1 screening interview(=95.9%). Prevalence of all depressive disorders were 10.5%(male 7.4%, female 12.8%); 8.7% in major depression(male 6.3%, female 10.6%), 0.5% in dysthymic disorder(male 0.4%, female 0.6%), and depressive disorder NOS 0.5%(male 0.2%, female 0.7%). A high risk of depressive disorder was found among elderly women(OR= 1.54, 95% CI 1.08-2.20) and among those with physical illnesses(OR=1.82, 95% CI 1.33-2.48), especially those with vascular risk factors(OR=1.96, 95% CI 1.43-2.69). CONCLUSION: The association between physical health and depression in old age is a consistent finding across world. Systemic efforts to reduce incidence of depression and especially to prevent and treat vascular risk factors may be able to improve mental health in the elderly.

Incidence and Risk Factors of Dementia in a Rural Area

OBJECTIVES: To survey the incidence and risk factors of dementia on a rural elderly cohort. METHODS: Two follow-up studies in 2000 and 2003 were done on 966 non-demented elderly residents who participated in 1st wave in 1996. A two-phase study was conducted using the Korean version of Psychogeriatric Assessment Scale in phase I and the diagnostic interview according to DSM-III R criteria by psychiatrists in stage II. RESULTS: Of the 966 elderly residents who had not dementia in 1996 prevalence study, 592 residents in 2nd wave and 508 residents in 3rd wave completed the incidence study. Dementia was incident in 96 residents. The annual incidence rates per 1000 persons were 27.2 (CI:22.2-33.2). Annual incidence rates were rapidly raised from 10.6 (CI:5.3-21.2) in the age range 65-69 years to 88.9 (CI:55.3-143) in the age range 85+. Older age was a risk factor of dementia (p<0.05), and Education was a preventive factor of dementia (p<0.001). But, female, history of depression, alcohol use history and tobacco use history were not risk factors. CONCLUSION: The annual incidence rates in Korea were higher than those of other countries. High percentage of no educated person (58.8%) in this community may be related to the higher incidence rates. Weighting to sex and age in normal elderly population in Korea at 2003, The annual incidence rates of dementia per 1000 persons were 25.2, and the numbers of newly incident elderly persons every year were approximately hundred thousand.

Practice Guidelines for the Manegement of Alzheimer's Disease

No abstract available.

Development of the Korean Version of Alzheimers Disease Assessment Scale(ADAS-K) to Assess Cognition in Dementia

OBJECTIVES: To develop the Korean version of Alzheimer`s Disease Assessment Scale(ADAS-K), an instrument for assessment of cognitive decline and behavioral symptoms seen in persons with Alzheimer`s disease METHOD: Community-dwelling elderly with Alzheimer`s disease(n=198) and mild cognitive impairment (n=30) participated in this study to evaluate reliabilities and validities of ADAS-K. RESULTS: The ADAS-K demonstrated a high degree of internal consistency and excellent interrater and test-retest reliability and high concurrent validity. Optimal cutoff points for the ADAS-K and ADAS-K-cog were 20/21(sensitivity 91%, specificity 83%) and 17/18(sensitivity 91%, specificity 93%). CONCLUSION: The ADAS-K is valid and reliable instrument in Korean elderly with Alzheimer`s disease, that may have potential to improve research outcomes and reduce the time and costs of research.

Development of the Korean Version of Disability Assessment for Dementia Scale(DAD-K) to Assess Function in Dementia

OBJECTIVES: To develop the Korean version of Disability Assessment for Dementia Scale(DAD-K), an instrument for functional disability for use with proxy-respondents of community-dwelling persons who have Alzheimer`s disease METHOD: Community-dwelling elderly and their caregivers with memory impairment(N=341) participated in this study to evaluate reliabilities and validities of DAD-K. RESULTS: The DAD-K demonstrated a high degree of internal consistency(Cronbach`s alpha=0.88) and excellent interrater(ICC=0.96) and test-retest(ICC=0.96) reliability and good concurrent validity. In addi- tion, it was found not to have age, education and gender bias. CONCLUSION: The DAD-K is valid and reliable instrument in Korean elderly with Alzheimer`s disease, that may help clinicians and caregivers of the population with Alzheimer`s disease make decisions regar- ding the choice of suitable interventions.

Validation of the Korean Version of Cambridge Cognitive Examination-Revised(CAMCOG-R) to Assist Dementia Diagnosis

BACKGROUND: The present study aims to examine the reliability and validity of a Korean version of the CAMCOG-R(CAMCOG-RK) in a clinical setting and an institution, that have been widely used to detect early dementia. METHODS: Study participants included 243 dementia sufferers, 68 mild cognitive impairment(MCI) suffers and 354 non-demented subjects. DSM-IV clinical criteria for dementia and Petersen's criteria for MCI were used as the 'gold' standards. The CAMCOG-R was translated into Korean and then back to English. Six items needed modifications for local usage. RESULTS: Interrater and test-retest scores calculated as intraclass correlation coefficients showed excel- lent for total score and all subscale scores of CAMCOG-RK. A strong concurrent validity was found with the MMSE-K score(r=0.82, p<0.01). Examination of the association between CAMCOG-R scores and socio- demographic variables(age, sex, and education) shows that age and education exerts a significant, and independent, effect upon performance. The eight age and education-specific cutoff point for dementia and MCI provided excellent sensitivity and specificity mostly more than 90%. CONCLUSION: The CAMCOG-RK was found to be an appropriate instrument to discriminate between demented and non-demented individuals and between individuals with MCI and without MCI in a clinical setting. Further studies should examine the psychometric characteristics of the CAMCOG-RK in a more varied sample.

Clinical Manifestations of Depressive Symptoms in Korean Elderly

OBJECTIVE: To analyze characteristics of depressive symptom manifestation in Korean elderly by use of the Psychogeriatric Assessment Scale-Korean Version (PAS-K). METHOD: In the two epidemiological studies conducted in Yoncheon and Ulsan separately, PAS-K (Psychogeriatric Assessment Scale-Korean Version) was used as a common screening tool for depression in aged persons (65+). We analyzed the symptom characteristics in total subjects (n=1.641) by factor analysis and compared depressive symptomatology between male and female, urban and rural, educated and uneducated persons. Chi-square method was used to evaluated the differences in positive response rates of each depressive symptoms, and also item response theory was used to compare depressive symptomatology between male and female subject groups. RESULTS: Two factor structure that comprises 'combined emotional, cognitive and somatic factor' and 'sleep factor' was found in female, rural and uneducated groups. While, three factor structure composed of 'emotional factor', 'combined cognitive and somatic factor' and 'sleep factor' was found in male, urban and educated groups. Women endorsed significantly more depressive symptoms than men. Depressive mood, fatigue, restlessness, thoughts mixed up and suicide idea were more prevalent in female group. However, women reported their symptoms, especially emotional symptoms like depressive mood, restlessness, suicide idea, in less severe state of depression than men. In the evaluation of each item characteristics, most items were relevant in their item characteristics for the assessment of depressive symptoms in Korean elderly. However, 'hypnoticsalcohol use' item had very low correlation coefficient with total symptom score and it was less discriminative than other symptom items. CONCLUSION: Symptom characteristics of depression in Korean aged persons were different between groups according to sex, urbanicity and education level. An influence of Confucian culture on different symptom expression between male and female groups should be considered.

A Retrospective Pharmacoeconomic Study of Risperidone versus Olanzapine / 대한정신약물학회지

OBJECTIVE: The study aims to compare daily treatment costs of risperidone and olanzapine in the Korean RODOS data. METHODS: Retrospective inpatient chart review yielded pharmacoeconomic data of 1096 patients with schizophrenia and schizoaffective disorder. RESULTS: The mean+/-SD daily effective dose of olanzapine treatment was 14.9+/-5.3 mg compared to 5.1+/-1.8 mg for risperidone. Use of concomittant neuroleptics was higher in olanzapine group (risperidone 29%;olanzapine 35%;p=0.034), while use of other concomitant drugs was higher in risperidone group (risperidone 97%;olanzapine 90%;p<0.001). The mean+/-SD total costs of all inpatient drugs was significantly higher (p<0.001) for olanzapine (338, 431 Korean Won+/-289, 884) than risperidone (114, 775 Korean Won+/-97, 835). Although this difference in the average total costs in part reflects the longer treatment duration for olanzapine compared to risperidone (52 day versus 43 day), the cost difference remained when looking at costs on a daily basis and when correcting the baseline differences. The mean+/-SD daily costs of all inpatient drugs was significantly higher (p<0.001) for olanzapine (9, 407 Korean Won+/-10, 767) than risperidone (4, 475 Korean Won+/-4, 312). CONCLUSION: When both olanzapine and risperidone are considered appropriate, it is desirable to choose risperidone first in terms of the pharmacoeconomic consideration of the cost of these drugs.

Dementia in Korea: Trend and Projection

While known risk factors of Alzheimer's disease (i.e. age, gender. ApoE genotype, family history of dementia) are difficult to modify, risk factors for vascular dementia (i.e. hypertension, stroke, heart disease, hyperlipidemia, smoking) are comparatively easier to modify. Prevalence of dementia is directly related to mortality of dementia and incidence of vascular dementia. Increase in the prevalence of dementia due to population aging will burden greatly on a society. Future projection of dementia has great health economic implication. Family memebers have taken care of almost all the elderly who needs care due to dementia or stroke. However, in the near future, they may have to be looked after by the government instead of a family due to nuclear family and aging of offsprings. In spite that we can keep prevalence of dementia constant at present by active and persistent efforts to control dementia and its risk factors, number of dementia sufferers will grow rapidly with the increase of aged population. Return to the Confucian tradition of filial piety, in addition to the effective prevention and treatment of dementia and its risk factors, may tackle aging crisis of 21st century. However, Korean government has to give up the 'family support first, public support next' policy that has been accepted implicitly and adopt new 'public support under the aid of family support' policy.

Diagnostic Capability of the Cognitive Assessment and Reference Diagnoses System(CARDS)

BACKGROUND: Recent therapeutic advances to delay the progression of dementia have renewed calls to improve early detection and management of individuals with dementia. A new computerized neuropsychological interview and clinical examination, the Cognitive Assessment and Reference Diagnosis System (CARDS) was developed to incorporate in a single instrument all the information required to make an accurate clinical diagnosis of dementia, its subtype, depression and delirium, to present reference diagnoses just after completion of tests, and to detect early dementia. This study aims to verify the diagnostic capability of the CARDS. METHODS: The CARDS was administered to 56 dementia patients (38 Alzheimer's disease, 18 vascular dementia) as well as 40 nondemented subjects. To evaluate the sensitivity and specificity of the CARDS, we compared the CARDS diagnosis with the clinician's diagnosis on dementia, Alzheimer's disease, vascular dementia and depression. To test diagnostic capability of the CARDS in the diagnosis of early dementia, we compared mean scores of total and subscales in the CARDS of GDS stage 3 group with those of GDS stage 4 group. RESULTS: The CARDS demonstrated high levels of sensitivity and specificity in the diagnosis of dementia, AD, VaD and depression. Mean CARDS scores for total and 3 subscales (amnesia, aphasia, agnosia) in GDS stage 3 group were significantly different from those of GDS stage 4 group (p<0.001). CONCLUSION: We demonstrated that CARDS is valid instrument not only for dementia diagnosis but also for detection of early dementia.

Reliability and Validity of the Korean Version of GMS-AGECAT / 신경정신의학

OBJECTIVES: This study aims to confirm the reliability and validity of the GMS-AGECAT(Geriatric Mental State-Automated Geriatric Examination for Computer Assisted Taxonomy in a Korean elderly population. METHODS: Translation committee developed Korean version GMS translating GMS-A3 after preliminary studies. Few changes from the original English version were necessary. A random sample(N= 1256 of the elderly(65+ years in Asan, community was assessed for diagnostic validity. A two-phase study was designed: Korean version of GMS-AGECAT, MMSE and GDS rated by lay interviewer and clinical assessment by psychiatrists according to DSM-IV. A consecutive hospital sample(N=28 of the elderly(65+ years admitted in Hangang Sacred Heart Hospital was assessed for reliability, concurrent & procedural validity. RESULTS: Reliability coefficients of GMS-AGECAT diagnosis were Inter-rater kappa 0.78 and test-retest kappa 0.56. Correlation coefficients for concurrent validity were 0.76 with MMSE and 0.73 with GDS. Procedural validity of psychiatrist's GMS-AGECAT diagnosis and lay-interviewers' were as follow: case/ no case distinction sensitivity 95.5%, specificity 75%; organicity distinction sensitivity 100%, specificity 83.3% and depression distinction, sensitivity 92.3%, specificity 100%. Diagnostic validity of DSM-IV diagnoses and GMS-AGECAT diagnoses were: case/ no case distinction sensitivity 92.7%, specificity 81%, dementia distinction sensitivity 77.3%, specificity 92.1% and depression distinction sensitivity 83.6%, specificity 84.1%. CONCLUSIONS: This study confirms the reliability and validity of the GMS-AGECAT in Korean elderly. Korean version GMS can be used in the international comparison studies.

Comorbid Mental Disorders Among the Patients with Alcohol Abuse and Dependence in Korea

This study investigated the patterns of alcohol disorder comorbidity with other psychiatric disorders, using Korean nationwide epidemiological data. By two-stage cluster sampling, 5,176 adult household residents of Korea were interviewed using the Korean version of the Diagnostic Interview Schedule. Psychiatric disorders strongly associated with alcohol disorders were, other drug abuse or dependence, major depression, simple phobia, antisocial personality disorder, tobacco dependence, and pathological gambling. Male alcoholics had a tendency to begin with tobacco dependence, and some male pathological gamblers first had alcohol disorders. The presence of comorbid psychiatric disorders was associated with a more severe form and the later onset of alcohol disorders, and associated with help-seeking for alcohol abuse/dependence.