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Drug and Alcohol Dependence xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Full length article
Co-occurring psychiatric and drug use disorders among sexual minority men with lifetime alcohol use disorders Ji Hyun Lee a , Kristi E. Gamarel b , Christopher W. Kahler a , Brandon D.L. Marshall a , Jacob J. van den Berg c , Kendall Bryant d , Nickolas D. Zaller e , Don Operario a,∗ a
School of Public Health, Brown University, Providence, RI, USA Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA c Division of Infectious Diseases, Miriam Hospital and Alpert Medical School of Brown University, Providence, RI, USA d National Institute on Alcohol Abuse and Alcoholism, Rockville, MD, USA e Fay W. Boozman College of Public Health, University of Arkansas, Little Rock, AR, USA b
a r t i c l e
i n f o
Article history: Received 19 October 2014 Received in revised form 15 March 2015 Accepted 17 March 2015 Available online xxx Keywords: Alcohol use Men who have sex with men (MSM) Diagnostic co-occurrence
a b s t r a c t Background: Emerging evidence indicates multiple health risks associated with harmful alcohol use among sexual minority men in the United States. In particular, sexual minority men with alcohol use disorders (AUD) might have greater co-occurring health problems compared with heterosexual men. We used nationally representative data to compare the prevalence of diagnostic co-occurring psychiatric disorders and drug use disorders (DUD) among sexual minority men with AUD compared with heterosexual males with a lifetime AUD diagnosis. Methods: We analyzed data from 6899 adult males with AUD participating in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Using weighted multivariable logistic regression models, we compared the odds of lifetime diagnosis of mood disorders, anxiety disorders, and drug use disorders in sexual minority and heterosexual adult males with AUD. Results: Of participants included in this analysis, 176 (2.6%) self-identified as a sexual minority. In adjusted analyses, sexual minority men with AUD were more likely than heterosexual men with AUD to have any mood disorder (including major depressive episode), any anxiety disorder (including panic disorder without agoraphobia, specific phobia, posttraumatic stress disorder, and generalized anxiety disorder), and lifetime DUD. Conclusions: The elevated co-occurrence of psychiatric disorders and DUD among sexual minority men with AUD suggests that future research is warranted. A better understanding of the etiology of diagnostic co-occurring mental health and substance use disorders among sexual minority men is needed in order to develop effective integrated prevention and treatment programs. © 2015 Published by Elsevier Ireland Ltd.
1. Introduction Alcohol use disorders (AUDs) are prevalent in the United States population, with estimates of lifetime AUD prevalence ranging from 8.3% to 30.3% (Hasin et al., 2007). Over the past decade, a growing body of epidemiological evidence has documented disproportionately higher rates of AUD among sexual minority men in the United States (Gruskin and Gordan, 2006 Coffin et al. 2014 Drabble et al., 2005; McCabe et al., 2009). For example, one nationally representative sample found that sexual minority men had more than
∗ Corresponding author. Tel.: +001 401 863 6657. E-mail address: Don [email protected] (D. Operario).
three times the odds of reporting alcohol dependence compared to heterosexual men (McCabe et al., 2009). A high prevalence of diagnostic co-occurring substance use disorders and mental health problems, such as depressive symptoms, have previously been reported in studies of people with AUD (Hesselbrock et al., 1985; Swendsen and Merikangas, 2000; Grant et al., 2004; Conway et al., 2006; Natj et al., 2011). The cooccurrence of substance use disorders and mental health problems is alarming as AUD has been associated with mortality, liver cirrhosis, certain cancers, and unintentional injuries (Compton et al., 2007; Gonzales et al., 2014; Hasin et al., 2007). A number of studies suggest that sexual minority adults have a greater risk of both psychiatric and substance use disorders compared with heterosexual populations (Bostwick et al., 2010; Cochran et al., 2003;
http://dx.doi.org/10.1016/j.drugalcdep.2015.03.018 0376-8716/© 2015 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Lee, J.H., et al., Co-occurring psychiatric and drug use disorders among sexual minority men with lifetime alcohol use disorders. Drug Alcohol Depend. (2015), http://dx.doi.org/10.1016/j.drugalcdep.2015.03.018
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Institute of Medicine, 2011). However, there is limited populationlevel research that examines whether sexual minorities with AUD experience greater diagnostic co-occurring psychiatric and substance use problems compared with heterosexuals. There is reason to expect a heightened risk for diagnostic co-occurring psychiatric problems among sexual minority populations with AUD. Studies have found that cumulative exposure to stress related to societal discrimination can have deleterious effects on mental and behavioral health of sexual minority populations (Bloomfield et al., 2011; Meyer, 2003). For example, using data from a national representative survey, one study found that lesbian, gay, and bisexual adults who reported greater exposure to discrimination also had significantly higher risk for past-year substance use disorder (McCabe et al., 2010). Other recent studies have found that sexual minority individuals residing in states that lacked protective policies against bias (i.e., laws against hate crimes, employment discrimination) have higher prevalence of alcohol, drug, and mental health disorders than those who live in states with protective policies (Pachankis et al., 2014; Hatzenbuehler et al., 2009. Thus, AUD may be especially likely to emerge in sexual minority individuals in the context of multiple psychiatric disorders as a result of discrimination. The present study seeks to extend existing evidence by examining the potential disparities in diagnostic co-occurring health conditions between adult heterosexual and sexual minority men with AUD. The study uses data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a populationbased survey conducted by the National Institute of Alcohol Abuse and Alcoholism (NIAAA). Our aims were to utilize the NESARC to: (i) compare heterosexual and sexual minority men on the prevalence of diagnostic co-occurring psychiatric and drug use disorders among men with AUD; and (ii) examine whether disparities in the prevalence of co-occurring disorders persist between sexual minority and heterosexual men after adjustment for potential sociodemographic confounders.
Hasin et al., 1997). Diagnosis of lifetime alcohol abuse required that respondents satisfied at least 1 of the 4 abuse criteria within any 12-month period. Diagnosis of lifetime alcohol dependence required that respondents satisfied at least 3 of the 7 dependence criteria within any 12-month period. Any participant who met diagnostic criteria for either lifetime alcohol abuse or dependence was defined as having lifetime AUD. Lifetime psychiatric disorders: Lifetime psychiatric disorders were assessed using the AUDADIS-IV to determine the presence of any lifetime DSM-IV psychiatric disorders. The mood disorders assessed included major depressive episode, mania, dysthymia and hypomania. Anxiety disorders included panic disorder with and without agoraphobia, agoraphobia, social phobia, specific phobia, posttraumatic stress disorder and generalized anxiety disorder. Reliability and validity of the NESARC mood and anxiety disorder measures are extensively discussed in detail elsewhere (Grant and Kaplan, 2005; Grant et al., 2004). Lifetime drug use disorders: Lifetime drug use disorders were assessed in the NESARC included DSM-IV diagnoses of abuse and dependence for each of 10 separate categories of medical and illicit drugs: sedatives, tranquilizers, opiates, stimulants, cocaine, cannabis, hallucinogen, inhalants/solvents, heroin, and other drugs. In this study, drug use disorders were categorized as any prescription drug use disorder (sedatives, tranquilizers, opioids, and amphetamine), cannabis use disorder, other drug use disorder (hallucinogens, cocaine, inhalants/solvents, heroin and other drug), and any drug use disorder, which included any of these drug use disorders. 2.3. Statistical analysis To assess whether sexual orientation was significantly associated with sociodemographic characteristics, and diagnostic co-occurring psychiatric and drug use disorders, we first compared sexual minority-identified versus heterosexual participants using design-based Rao–Scott correction F-statistic chi-square tests. Next, a series of multivariable logistic regression analyses were conducted to compare sexual minority versus heterosexual participants who met criteria for a lifetime AUD on diagnostic co-occurring psychiatric and drug use disorders, adjusting for sociodemographic variables of interest (age, race/ethnicity, marital status, education, employment, family income, and past-year health insurance). Adjusted odds ratios (AOR) and 95% CIs are reported. All analyses took into account the analytical weights and clustering within sample strata using Taylor linearization implemented via STATA survey commands. All analyses were conducted using STATA Statistical Software, version 13.0. All p-values are two-sided.
3. Results 3.1. Sociodemographic characteristics
2. Methods 2.1. Sample The 2004–2005 NESARC (Wave 2) collected data from a nationally representative sample of 34,653 civilian, non-institutionalized U.S. adults, ages 18 and older. Data were collected via face-to-face interviews. Sample weights were calculated to ensure that the weighted sample represented the U.S. adult non-institutionalized population based on the 2000 census. Detailed information of the NESARC survey methods and procedures is described elsewhere (Grant and Dawson, 2006; Grant and Kaplan, 2005). Given the documented gender differences in mental health and co-occurring substance use disorder (Gattis et al., 2012), we only included in the sample men who self-identified themselves as heterosexual or sexual minority (gay, bisexual, or not sure), and who met the diagnostic criteria for lifetime AUD (n = 6899).
Of the 6899 adult male participants with AUD who were included in this analysis, 176 (2.6% weighted) identified as a sexual minority and 6723 (97.4%) identified as heterosexual. Table 1 shows that sexual minority men with AUD were significantly less likely than heterosexual men with AUD to be married or living with partner, less likely to be employed full time, more likely to have completed college or higher degree, and more likely to have a past year family income
ARTICLE IN PRESS
DAD-5523; No. of Pages 6
Drug and Alcohol Dependence xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Full length article
Co-occurring psychiatric and drug use disorders among sexual minority men with lifetime alcohol use disorders Ji Hyun Lee a , Kristi E. Gamarel b , Christopher W. Kahler a , Brandon D.L. Marshall a , Jacob J. van den Berg c , Kendall Bryant d , Nickolas D. Zaller e , Don Operario a,∗ a
School of Public Health, Brown University, Providence, RI, USA Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA c Division of Infectious Diseases, Miriam Hospital and Alpert Medical School of Brown University, Providence, RI, USA d National Institute on Alcohol Abuse and Alcoholism, Rockville, MD, USA e Fay W. Boozman College of Public Health, University of Arkansas, Little Rock, AR, USA b
a r t i c l e
i n f o
Article history: Received 19 October 2014 Received in revised form 15 March 2015 Accepted 17 March 2015 Available online xxx Keywords: Alcohol use Men who have sex with men (MSM) Diagnostic co-occurrence
a b s t r a c t Background: Emerging evidence indicates multiple health risks associated with harmful alcohol use among sexual minority men in the United States. In particular, sexual minority men with alcohol use disorders (AUD) might have greater co-occurring health problems compared with heterosexual men. We used nationally representative data to compare the prevalence of diagnostic co-occurring psychiatric disorders and drug use disorders (DUD) among sexual minority men with AUD compared with heterosexual males with a lifetime AUD diagnosis. Methods: We analyzed data from 6899 adult males with AUD participating in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Using weighted multivariable logistic regression models, we compared the odds of lifetime diagnosis of mood disorders, anxiety disorders, and drug use disorders in sexual minority and heterosexual adult males with AUD. Results: Of participants included in this analysis, 176 (2.6%) self-identified as a sexual minority. In adjusted analyses, sexual minority men with AUD were more likely than heterosexual men with AUD to have any mood disorder (including major depressive episode), any anxiety disorder (including panic disorder without agoraphobia, specific phobia, posttraumatic stress disorder, and generalized anxiety disorder), and lifetime DUD. Conclusions: The elevated co-occurrence of psychiatric disorders and DUD among sexual minority men with AUD suggests that future research is warranted. A better understanding of the etiology of diagnostic co-occurring mental health and substance use disorders among sexual minority men is needed in order to develop effective integrated prevention and treatment programs. © 2015 Published by Elsevier Ireland Ltd.
1. Introduction Alcohol use disorders (AUDs) are prevalent in the United States population, with estimates of lifetime AUD prevalence ranging from 8.3% to 30.3% (Hasin et al., 2007). Over the past decade, a growing body of epidemiological evidence has documented disproportionately higher rates of AUD among sexual minority men in the United States (Gruskin and Gordan, 2006 Coffin et al. 2014 Drabble et al., 2005; McCabe et al., 2009). For example, one nationally representative sample found that sexual minority men had more than
∗ Corresponding author. Tel.: +001 401 863 6657. E-mail address: Don [email protected] (D. Operario).
three times the odds of reporting alcohol dependence compared to heterosexual men (McCabe et al., 2009). A high prevalence of diagnostic co-occurring substance use disorders and mental health problems, such as depressive symptoms, have previously been reported in studies of people with AUD (Hesselbrock et al., 1985; Swendsen and Merikangas, 2000; Grant et al., 2004; Conway et al., 2006; Natj et al., 2011). The cooccurrence of substance use disorders and mental health problems is alarming as AUD has been associated with mortality, liver cirrhosis, certain cancers, and unintentional injuries (Compton et al., 2007; Gonzales et al., 2014; Hasin et al., 2007). A number of studies suggest that sexual minority adults have a greater risk of both psychiatric and substance use disorders compared with heterosexual populations (Bostwick et al., 2010; Cochran et al., 2003;
http://dx.doi.org/10.1016/j.drugalcdep.2015.03.018 0376-8716/© 2015 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Lee, J.H., et al., Co-occurring psychiatric and drug use disorders among sexual minority men with lifetime alcohol use disorders. Drug Alcohol Depend. (2015), http://dx.doi.org/10.1016/j.drugalcdep.2015.03.018
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Institute of Medicine, 2011). However, there is limited populationlevel research that examines whether sexual minorities with AUD experience greater diagnostic co-occurring psychiatric and substance use problems compared with heterosexuals. There is reason to expect a heightened risk for diagnostic co-occurring psychiatric problems among sexual minority populations with AUD. Studies have found that cumulative exposure to stress related to societal discrimination can have deleterious effects on mental and behavioral health of sexual minority populations (Bloomfield et al., 2011; Meyer, 2003). For example, using data from a national representative survey, one study found that lesbian, gay, and bisexual adults who reported greater exposure to discrimination also had significantly higher risk for past-year substance use disorder (McCabe et al., 2010). Other recent studies have found that sexual minority individuals residing in states that lacked protective policies against bias (i.e., laws against hate crimes, employment discrimination) have higher prevalence of alcohol, drug, and mental health disorders than those who live in states with protective policies (Pachankis et al., 2014; Hatzenbuehler et al., 2009. Thus, AUD may be especially likely to emerge in sexual minority individuals in the context of multiple psychiatric disorders as a result of discrimination. The present study seeks to extend existing evidence by examining the potential disparities in diagnostic co-occurring health conditions between adult heterosexual and sexual minority men with AUD. The study uses data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a populationbased survey conducted by the National Institute of Alcohol Abuse and Alcoholism (NIAAA). Our aims were to utilize the NESARC to: (i) compare heterosexual and sexual minority men on the prevalence of diagnostic co-occurring psychiatric and drug use disorders among men with AUD; and (ii) examine whether disparities in the prevalence of co-occurring disorders persist between sexual minority and heterosexual men after adjustment for potential sociodemographic confounders.
Hasin et al., 1997). Diagnosis of lifetime alcohol abuse required that respondents satisfied at least 1 of the 4 abuse criteria within any 12-month period. Diagnosis of lifetime alcohol dependence required that respondents satisfied at least 3 of the 7 dependence criteria within any 12-month period. Any participant who met diagnostic criteria for either lifetime alcohol abuse or dependence was defined as having lifetime AUD. Lifetime psychiatric disorders: Lifetime psychiatric disorders were assessed using the AUDADIS-IV to determine the presence of any lifetime DSM-IV psychiatric disorders. The mood disorders assessed included major depressive episode, mania, dysthymia and hypomania. Anxiety disorders included panic disorder with and without agoraphobia, agoraphobia, social phobia, specific phobia, posttraumatic stress disorder and generalized anxiety disorder. Reliability and validity of the NESARC mood and anxiety disorder measures are extensively discussed in detail elsewhere (Grant and Kaplan, 2005; Grant et al., 2004). Lifetime drug use disorders: Lifetime drug use disorders were assessed in the NESARC included DSM-IV diagnoses of abuse and dependence for each of 10 separate categories of medical and illicit drugs: sedatives, tranquilizers, opiates, stimulants, cocaine, cannabis, hallucinogen, inhalants/solvents, heroin, and other drugs. In this study, drug use disorders were categorized as any prescription drug use disorder (sedatives, tranquilizers, opioids, and amphetamine), cannabis use disorder, other drug use disorder (hallucinogens, cocaine, inhalants/solvents, heroin and other drug), and any drug use disorder, which included any of these drug use disorders. 2.3. Statistical analysis To assess whether sexual orientation was significantly associated with sociodemographic characteristics, and diagnostic co-occurring psychiatric and drug use disorders, we first compared sexual minority-identified versus heterosexual participants using design-based Rao–Scott correction F-statistic chi-square tests. Next, a series of multivariable logistic regression analyses were conducted to compare sexual minority versus heterosexual participants who met criteria for a lifetime AUD on diagnostic co-occurring psychiatric and drug use disorders, adjusting for sociodemographic variables of interest (age, race/ethnicity, marital status, education, employment, family income, and past-year health insurance). Adjusted odds ratios (AOR) and 95% CIs are reported. All analyses took into account the analytical weights and clustering within sample strata using Taylor linearization implemented via STATA survey commands. All analyses were conducted using STATA Statistical Software, version 13.0. All p-values are two-sided.
3. Results 3.1. Sociodemographic characteristics
2. Methods 2.1. Sample The 2004–2005 NESARC (Wave 2) collected data from a nationally representative sample of 34,653 civilian, non-institutionalized U.S. adults, ages 18 and older. Data were collected via face-to-face interviews. Sample weights were calculated to ensure that the weighted sample represented the U.S. adult non-institutionalized population based on the 2000 census. Detailed information of the NESARC survey methods and procedures is described elsewhere (Grant and Dawson, 2006; Grant and Kaplan, 2005). Given the documented gender differences in mental health and co-occurring substance use disorder (Gattis et al., 2012), we only included in the sample men who self-identified themselves as heterosexual or sexual minority (gay, bisexual, or not sure), and who met the diagnostic criteria for lifetime AUD (n = 6899).
Of the 6899 adult male participants with AUD who were included in this analysis, 176 (2.6% weighted) identified as a sexual minority and 6723 (97.4%) identified as heterosexual. Table 1 shows that sexual minority men with AUD were significantly less likely than heterosexual men with AUD to be married or living with partner, less likely to be employed full time, more likely to have completed college or higher degree, and more likely to have a past year family income
