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Psychiatric Comorbidity in Individuals with an Alcohol Use Disorder
High rates of comorbid psychiatric disorders have been found in both clinical and community samples of alcohol-dependent in-dividuals. These studies show a consistent association between alcohol abuse/dependence and a variety of other psychiatric symptoms and disorders. The Epidemiological Catchment Area (ECA) study, for example, revealed that 36.6% of those with a lifetime alcohol use disorder received at least one other psychi-atric diagnosis, which is nearly double the rate for community respondents with no lifetime alcohol disorder (Regier et al., 1990). The evidence from the NCS study showed that cooccur-ring disorder is more likely with alcohol dependence than alcohol abuse (Kessler et al., 1997). Among individuals with one or more psychiatric disorders, 22.3% also had a lifetime alcohol disor-der, substantially greater than the overall lifetime prevalence of alcohol abuse/dependence (13.5%). Women diagnosed with an alcohol disorder appear to be at greater risk for a comorbid psychiatric disorder. The NCS found that 72% of females with a lifetime alcohol abuse diagnosis had experienced one or more cooccurring psychiatric disorders, compared with 57% of men who had a lifetime history of alcohol abuse. While the prevalence of comorbid disorders was greater with alcohol dependence, the gender differential was smaller: 86% of women and 78% of men with lifetime alcohol dependency had had other lifetime DSM-III-R disorders.
The most frequent cooccurring diagnoses are for other drug use disorders, conduct disorder, antisocial personality dis-order, anxiety disorders and affective disorders. The relative risks for different types of disorder vary somewhat by gender. Among women, anxiety and affective disorders are the most common cooccurring disorders. Among men with a history of al-cohol abuse or dependence, drug disorders and conduct disorder account for the largest proportion of comorbid cases.
Both community and clinical studies underscore the im-portance of ASPD and drug abuse/ dependence as comorbid di-agnoses in individuals with an alcohol disorder. The odds ratios obtained for these disorders in community studies indicate that these associations are elevated not only as a function of greater treatment-seeking behavior in affected individuals, but also be-cause of potential commonalities in the etiology and development of alcohol abuse/dependence. That is, genetic and/or psychoso-cial risk factors for the development of ASPD are likely to overlap with factors that increase risk for alcohol and drug use disorders. Similarly, the risk factors for alcohol and drug use disorders may overlap with those for schizophrenia and bipolar disorder. In contrast, although anxiety disorders and depression are highly prevalent in clinical samples of alcohol-dependent individuals, their association with alcohol dependence appears largely due to chance, since these disorders are also highly prevalent in the general population.
Given a high rate of psychiatric comorbidity, it is axiomatic that a careful psychiatric assessment be conducted in patients be-ing seen for alcohol treatment, and that alcohol use and associ-ated problems be evaluated in patients being seen primarily for other psychiatric conditions. Because the presence of comorbid disorders may have important implications for the development of alcoholism and its prognosis, the assessment of comorbid psy-chopathology is an essential element in the clinical evaluation. When comorbid diagnoses are present, an effort should be made to ascertain the order of onset of each disorder since treatment and prognosis may follow from such information.
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