Substance use disorders and treatment utilization among MDMA users: Results from The National Epidemiologic Survey on Alcohol and Related Conditions.

The study examined the prevalence and correlates of substance use disorders and treatment utilization among lifetime MDMA users. Secondary analyses were conducted on data from the 2001-2002 NESARC, a nationally representative survey of adults in the United States. Lifetime MDMA use was assessed, and MDMA users (n = 562) were compared to a matched sample of non-MDMA users. Substance use diagnoses were made using the AUDADIS - DSM-IV, and data on treatment utilization were collected. MDMA use was significantly related to lifetime and past year substance use disorders as well as treatment utilization in bivariate analyses. Multivariate analysis, however, showed that MDMA use was not related to lifetime substance use diagnosis or to treatment utilization. MDMA use still had the strongest association with past year substance use disorders.

Diagnosis, self-help, and maintenance care as key constructs in treatment research for "alcohol use disorders" (AUD).

OBJECTIVE: This study examines a sample of alcohol user treatment outcome studies to determine the amount of attention given to three areas of concern and cost-effectiveness in treatment research: patient diagnosis, use of self-help groups (e.g., Alcoholics Anonymous [AA]), and use of maintenance care services (also known as a "aftercare"). METHOD: A preliminary sample of 40 studies was coded for the degree of specific information provided to each of the three areas of interest. RESULTS: Eight studies in the sample did not mention the diagnostic criteria used to determine patient addiction, 18 did not mention use, referral, or recommendation of AA, and 20 did not mention use, referral, or recommendation of maintenance care services. CONCLUSIONS: As cost-effective additions to primary treatment, AA and maintenance care services deserve greater attention in the treatment of "substance abuse disorders." Researchers should also pay greater attention to patient diagnosis as an integral part of patient care. Finally, journal editors should institute minimum requirements for published reports ensuring that sufficient information on patient care is provided.

Factor structure of the Alcohol Use Disorders Identification Test (AUDIT) in a mental health clinic sample.

OBJECTIVE: To examine the factor structure of the Alcohol Use Disorders Identification Test (AUDIT) and to identify the implications of this structure for its clinical use. METHOD: The AUDIT was administered to mental health clinic outpatients (N = 197; 86% men) at high risk for alcohol-use disorders. Confirmatory and exploratory factor analyses were used to determine the underlying factor structure of the AUDIT for this high-risk population. RESULTS: Confirmatory analyses indicated that the a priori three- and one-factor solutions did not fit the observed data. The exploratory analyses supported a two-factor solution that included level of alcohol consumption and drinking problems, with both factors explaining substantial variance in AUDIT scores. These findings contrast the original three-factor design of the AUDIT and the conventional use of the AUDIT as a one-factor screening device with a single cutoff score. CONCLUSIONS: Other screening methods that incorporate this two-factor model may be important for mental health patient populations. Replication of these findings among other mental health samples is needed.

Psychotherapy research: basic or applied?

Borkovec and Miranda (1996) have argued that the "greatest progress in the development of increasingly useful interventions" (p. 14) will come from redefining comparative trials research on psychotherapy outcome as basic research. They foresee that such a reconceptualization will lead to the increased use of dismantling, parametric, and additive research strategies and that it will result in increasing collaboration with other basic researchers. The assumption that a redefinition will stimulate increased collaboration and specificity of causal mechanisms is questioned as are the assumptions that randomization, group comparison designs, and within therapist designs will lead inherently to more valid assessments of cause-effect relationships. Analyses of a randomized clinical trials study is used to illustrate how clinical research can be guided by theory to tease out causal relationships, within therapy, and within patient factors. Ultimately, a combination of research paradigms, including N = 1, clinical utility, and controlled research, will best provide answers to important questions of change mechanisms and treatment effectiveness. A simple reconceptualization, however, is not necessary to make this happen and belies the complexity and overlap of the problems to be addressed.

Immigrant families coping with schizophrenia. Behavioral family intervention v. case management with a low-income Spanish-speaking population.

BACKGROUND: This investigation compared the effectiveness and cross-cultural applicability of behavioural family management (BFM) and standard case management in preventing exacerbation of symptoms and relapse in schizophrenia. METHOD: Forty low-income Spanish-speaking people with a diagnosis of schizophrenia were randomly assigned to receive standard case management or behavioural family management after stabilisation with neuroleptic medication. RESULTS: Survival analyses indicated that among the less acculturated patients BFM was significantly related to greater risk of exacerbation of symptoms. Among the more acculturated patients, risk of exacerbation could be predicted by medication compliance but not by type of intervention. In analyses of symptom severity and functional status at 1-year follow-up, the level of patient acculturation was found to be significantly related to various measures of treatment outcome. CONCLUSION: Sociocultural factors affect responses to different types of intervention. The results did not support earlier findings of a beneficial effect of BFM when applied to a socioculturally diverse population.

An attributional analysis of expressed emotion in Mexican-American families with schizophrenia.

In this study we tested an attributional model of expressed emotion (EE) among Mexican-American families. A sample of 46 key family members of schizophrenic patients were measured on three dimensions: affect toward patient, controllability attributions, and level of EE. Consistent with an attributional model, we found that high EE families (defined on the basis of critical comments) viewed the illness and associated symptoms as residing within the patient's personal control, more so than did low EE families. We also found that attributions held by family members are related to their affective reactions. Specifically, family members who perceived the patient as having control over the symptoms of schizophrenia tended to express greater negative emotions such as anger and annoyance toward the patient than did family members who viewed the symptoms as beyond the patient's personal control. An examination of the types of affects found and their relationship to EE status is discussed, along with implications for this research.

One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the Epidemiologic Catchment Area study.

The associations between the one-month prevalence rates of mental disorders and sociodemographic characteristics were investigated for 18,571 people interviewed in the first-wave community samples of all 5 sites in the US National Institute of Mental Health (NIMH) Epidemiologic Catchment Area program. Men were found to have a significantly higher rate of cognitive impairment than women after controlling for the effects of age, race or ethnicity, marital status and socioeconomic status. Marital status was one of the most powerful correlates of mental disorder risk: the odds of separated or divorced people having any NIMH Diagnostic Interview Schedule disorder were twice that of married people after controlling for age, gender, race or ethnicity and socioeconomic status. The odds of those in the lowest socioeconomic status group having any Diagnostic Interview Schedule disorder was about 2.5 times that of those in the highest socioeconomic status group, controlling for age, gender, race or ethnicity and marital status. For all disorders except cognitive impairment, race or ethnicity did not remain statistically significant after controlling for age, gender, marital status and socioeconomic status.

Cross-cultural issues in the course and treatment of schizophrenia.

In conclusion, we strongly share the belief recently expressed by Lefley that "the dialogue on clinical and social implications of research on expressed emotion may play a positive role" in the provision of care through a mental health service system that enlists, supports, and trains diverse intra and extra-familial caregivers in the many therapeutic tasks required for the care of the person and family afflicted with schizophrenia. We regard such a prescription as applicable in all social and cultural contexts.

The meaning of expressed emotion: theoretical issues raised by cross-cultural research.

The finding that expressed emotion is associated with the course of psychiatric disorder has generated a great deal of clinical and research interest in expressed emotion as an important risk factor. Theoretical elucidation of the construct of expressed emotion has lagged considerably behind this interest, however. The authors contribute to a dialogue on what is inside the "black box" called expressed emotion. They argue that cross-cultural research can provide an empirical basis for the theoretical grounding of expressed emotion factors. A comparative approach reveals that the construct of expressed emotion is essentially cultural in nature. The constellation of emotions, attitudes, and behaviors that are indexed by the expressed emotion method represent cross-culturally variable features of family response to an ill relative. Questions surrounding the cultural validity of the construct of expressed emotion, the qualitative dimensions of expressed emotion, and statistically significant cross-cultural variations in expressed emotion profiles are discussed. Finally, the authors provide an outline of diverse (cultural, psychobiological, social-ecological) features of expressed emotion. Anthropological analysis of expressed emotion reveals that although expressed emotion indexes a Pandora's box of diverse features, culture provides the context of variation through which these factors are most productively analyzed.

Symptoms of major depression among Mexican-Americans and non-Hispanic whites.

The lifetime prevalence of symptoms of a major depressive episode was estimated in two large samples of randomly selected community residents that included many Mexican-Americans. Approximately 5% to 40% of the subjects reported each symptom cluster. The rates for Mexican-Americans born in the United States resembled those for non-Hispanic whites born in the United States; however, the rates for Mexican-Americans born in Mexico were lower in eight of nine symptoms clusters. Language differences did not account for this pattern. Cultural similarity to non-Hispanic whites born in the United States was associated with a higher rate of depressive symptoms.

Parental communication deviance and schizophrenia: a cross-cultural comparison of Mexican- and Anglo-Americans.

Levels of parental communication deviance (CD), as measured on the Thematic Apperception Test (TAT), were compared among families of schizophrenic patients in two culturally distinct groups. Spanish-speaking Mexican-American parents of schizophrenics completed the TAT in their native language, and CD was coded from their stories by a Spanish-speaking rater. Mexican-American parents had levels of CD that were nearly identical to those of a carefully matched sample of English-speaking Anglo-American parents. Factor scores that measure distinct subtypes of CD also did not differ across groups. The data suggest that levels of CD, despite discriminating between parents of schizophrenics and nonschizophrenics, do not vary across different languages and cultures.

Acculturation and the probability of use of health services by Mexican Americans.

How does level of acculturation affect the probability that Mexican Americans use general health, mental health, and human social services? We studied this question using data from a general population sample of Mexican Americans (N = 1,055). Data were elicited in face-to-face interviews. After controlling for sociodemographic and economic factors, health status, and insurance coverage, Mexican Americans who were less acculturated had significantly lower probabilities of an outpatient medical visit for physical health problems and of a visit to a mental health specialist or human service provider for emotional problems. The less acculturated with good perceived general health were especially unlikely to receive outpatient medical care. Having Medicaid coverage was associated with a larger increase in the probability of an inpatient medical admission for the more acculturated than for the less acculturated. Other individual characteristics had generally similar effects on use of medical and mental health services for both the more and the less acculturated Mexican Americans.

Anxiety disorders among Mexican Americans and non-Hispanic whites in Los Angeles.

This report from the Los Angeles site of the NIMH Epidemiologic Catchment Area study reveals significant ethnic and national origin differences in lifetime prevalence rates for three out of six specific, DSM-III-defined anxiety disorders. In the case of simple phobia, United States-born Mexican Americans report higher rates than native non-Hispanic whites or immigrant Mexican Americans, the latter two groups having similar rates. Mexican Americans born in the United States had higher rates of agoraphobia than immigrant Mexican Americans, and non-Hispanic whites reported higher lifetime rates of generalized anxiety disorder compared with both immigrant and native Mexican Americans. Neither ethnic nor national origin differences in lifetime prevalence rates were found for panic disorder, social phobia, and obsessive-compulsive disorder. Selective migration is postulated as a potential factor influencing prevalence differences between native and immigrant Mexican Americans.

Somatic symptom index (SSI): a new and abridged somatization construct. Prevalence and epidemiological correlates in two large community samples.

An abridged somatization construct (the Somatic Symptom Index) derived from the Diagnostic Interview Schedule's somatization disorder items was tested on community epidemiological samples to examine its prevalence, risk factors, and predictive value. The construct had a high prevalence (range, 4.4% to 20% compared with .03% to 0.7% for the full DSM-III somatization disorder diagnosis), was related to low socioeconomic status, female gender, older chronological age, and Hispanic ethnic background. The presence of this construct determined preferential use of medical services and predicted high indices of disability. The Somatic Symptom Index may have practical utility for clinical and community studies of somatoform phenomena.

Teaching transcultural psychiatry.

The ethnic diversity of patients in most training centers requires that attention be given to cultural issues affecting the psychiatric presentation and treatment of patients from different backgrounds. This paper describes programs in transcultural psychiatry for medical students, residents, and fellows that have been implemented and refined at UCLA over the past six years. Suggestions are offered for the development of such programs elsewhere.

The epidemiology of obsessive-compulsive disorder in five US communities.

The prevalence of obsessive-compulsive disorder was measured in five US communities among more than 18,500 persons in residential settings as part of the National Institute of Mental Health (Bethesda, Md)--sponsored Epidemiologic Catchment Area program. Lifetime prevalence rates ranged from 1.9% to 3.3% across the five Epidemiologic Catchment Area sites for obsessive-compulsive disorder diagnosed without DSM-III exclusions and 1.2% to 2.4% with such exclusions. These rates are about 25 to 60 times greater than had been estimated on the basis of previous studies of clinical populations.

One-month prevalence of mental disorders in the United States. Based on five Epidemiologic Catchment Area sites.

One-month prevalence results were determined from 18,571 persons interviewed in the first-wave community samples of all five sites that constituted the National Institute of Mental Health Epidemiologic Catchment Area Program. US population estimates, based on combined site data, were that 15.4% of the population 18 years of age and over fulfilled criteria for at least one alcohol, drug abuse, or other mental disorder during the period one month before interview. Higher prevalence rates of most mental disorders were found among younger people (less than age 45 years), with the exception of severe cognitive impairments. Men had higher rates of substance abuse and antisocial personality, whereas women had higher rates of affective, anxiety, and somatization disorders. When restricted to the diagnostic categories covered in international studies based on the Present State Examination, results fell within the range reported for European and Australian studies.

Factors affecting the probability of use of general and medical health and social/community services for Mexican Americans and non-Hispanic whites.

Are individual characteristics associated with use of general and mental health and human service sectors similar for Mexican Americans (MAs) and non-Hispanic whites (NHWs)? We addressed this question using data from the Los Angeles site of the NIMH Epidemiologic Catchment Area Program. A random sample of the general population of two mental health catchment areas was interviewed in 1983-1984. With four exceptions, individual variation in sociodemographic factors, insurance coverage, and health status had similar effects on the probability of use of the general and mental health and human service sector for both NHWs and MAs. Recent psychiatric disorder was associated with greater use of general medical providers for mental health care for both NHWs and MAs, but significantly more so for NHWs. Female NHWs were more likely to use the human service sector (e.g., social service agencies) than male NHWs, but gender had no effect on this type of use for MAs. Higher job status was associated with greater use of outpatient general medical services, but significantly more so for NHWs than MAs. By contrast, having private health insurance was associated with a greater increase in use of outpatient general medical services for MAs than for NHWs.