ORIGINAL ARTICLE
Psychiatric and Substance Use Disorders
in South Florida
Racial/Ethnic and Gender Contrasts in a Young Adult Cohort
R. Jay Turner, PhD; Andres G. Gil, PhD
Background: Prevalence rates of psychiatric and substance
use disorders among young adults in South Florida are presented. Unique aspects of the study include the large sample
size, its ethnic diversity, and the fact that a substantial proportion of Hispanic participants were foreign born.
Methods: This study builds on a previous cohort study
of students who entered middle school in 1990. A random subsample of this representative cohort (N=1803)
was interviewed between 1998 and 2000 when most were
between 19 and 21 years of age. Disorders were assessed
through computer-assisted personal interviews utilizing the DSM-IV version of the Michigan Composite International Diagnostic Interview.
Results: More than 60% of the sample met lifetime criteria for 1 or more study disorders, and 38% did so within
the preceding year. Childhood conduct and major depressive and alcohol abuse disorders were the most preva-
C
From the Life Course and
Health Research Center and
the School of Social Work
of the College of Health
and Urban Affairs, Florida
International University,
Miami.
lent. Although rates of affective and anxiety disorders in
females were double that in males, this gender difference
disappeared when attention-deficit/hyperactivity disorder, conduct disorders, and antisocial personality disorders were also considered (46.6% vs 45.7% for females vs
males, respectively). Substantially lower rates were observed among African Americans for depressive disorders and substance abuse and dependence. Among Hispanics, rates tend to be lower among the foreign-born in
comparison with their US-born counterparts, particularly for the substance disorders.
Conclusions: The documented presence of psychiatric
and substance disorders in middle and high school populations emphasizes the importance of prevention efforts
in school settings. Research on the origins of ethnic and
nativity differences is called for.
Arch Gen Psychiatry. 2002;59:43-50
REDITABLE information
on the community prevalence and demographic
correlates of psychiatric
and substance use disorders has been available in published form
for little more than a decade. Based on data
obtained from 5 separate and largely urban sites, the Epidemiologic Catchment
Area Study (ECA) provided estimates of lifetime and current psychiatric and substance use disorders within and across
African American, Hispanic, and nonHispanic white subpopulations.1 Subsequently, the National Comorbidity Survey
(NCS)2 employed a nationally representative sample of more than 8000 persons between the ages of 15 and 54 to provide estimates of the prevalence of psychiatric and
substance use disorders and their social and
ethnic distributions. A summary of the ECA
and NCS findings has recently been presented by Tohen et al.3 Recent advances have
also been made toward estimating the com-
(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 59, JAN 2002
43
munity burden of substance use and psychiatric disorders among children and adolescents 9 to 18 years of age.4-7
These studies have been of immense
theoretical and practical significance because they have (1) produced estimates of
the true prevalence of specific psychiatric disorders in the community using welldefined diagnostic criteria; (2) provided
fundamental information on the chronicity, course, and comorbidity of psychiatric disorders; (3) provided a basis for estimating the extent and nature of unmet
service needs; and (4) identified subpopulations most in need of, or who might benefit most from prevention efforts.
This article is based on a new study
within this tradition. It presents findings
on the prevalence and demographic distributions of psychiatric and substance use
disorders among a representative cohort
of 1803 young adults. Most participants
(93%) were between 19 and 21 years of
age when interviewed between 1998 and
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METHODS
SAMPLE
This study builds on a previous 3-wave investigation based
in the Miami-Dade public school system.8 All 48 of the county’s public middle schools and all 25 public high schools as
well as alternative schools had participated. Questionnaires
were administered annually between 1990 and 1993 beginning in grades 6 and 7 and finishing when participating students were in grades 8 and 9. Consent forms were sent to parents of the total population of 9763 male students scheduled
to enter sixth and seventh grades, and of 669 female students from 6 schools selected to approximate the overall ethnic composition of county middle schools. Of these 10432
prospective participants, completed questionnaires were obtained from 7386 at wave 1, from 6646 at wave 2, and from
5924 at wave 3. Detailed analyses provided assurance that wave
1 participants were highly representative of the population
from which they were drawn and that this was also true for
the wave 3 participants, despite a nearly 20% attrition across
the 3 data points.8
Within the confines of ethnicity criteria, all female participants in the earlier investigation (n=410), and a random
sample of 1273 male participants, were ultimately selected
for follow-up. Because a relatively small number of girls were
included in the parent study, a supplementary sample was
randomly drawn from the Miami-Dade county 1990 sixthand seventh-grade class roster. The Figure summarizes the
results of fieldwork efforts. Overall, 70.1% of those we searched
for and attempted to recruit to the study were successfully
interviewed. By far, the greatest loss occurred among the new
sample of girls who had no involvement in the earlyadolescent study. A success rate of 76.4% was achieved among
First 3 Waves
Follow-up for
Wave 4
Follow-up Interviews for Wave 4
Year 1998-2000
Sampling Frame
N = 10 432
Sampling
Selection: 1683
Boys: 1273
Girls: 410
Wave 1
6th/7th Grade
(1990/1991)
n = 7386
Consent: 70.8%
Success
Rate
Wave 2
7th/8th Grade
(1991/1992)
n = 6646
Attrition: 10.0%
Boys:
956
Girls:
330
(80.5%)
New Girls:
517
(58.2%)
(70.1%)
Total:
1803
(75.1%)
Supplementary
Female Sampling
Selection From Original
1990 6th/7th Grade
Class Rosters: 888
Wave 3
8th/9th Grade
(1993)
n = 5924
Attrition: 19.8%
Sampling framework.
2000. The results constitute a unique contribution in
several respects. First, we believe that these data are
from the largest sample within this age range so far
studied in the United States. Second, this is among the
(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 59, JAN 2002
44
those in the original sample, despite the fact that many had
left home for college or for other reasons.
Those interviewed were compared with the total sample
of individuals drawn from the original study population on
28 early-adolescent behaviors and family characteristics of
possible relevance to mental health or substance abuse risk
(analyses not shown). No statistically significant differences were observed. Comparisons were also made with
respect to school dropout. Among those interviewed, 20.5%
reported that they had dropped out of high school. This
corresponds closely with rates reported by the school board
on the same student cohort of 21.1% for boys and 15.2%
for girls (data available at: http://www.dade.k12.fl.us/
eema /abstract/outcome6.htm, accessed November 28,
2000). These comparisons and the 76.4% follow-up success rate allow the conclusion that our sample is representative of the population from which it was drawn. In contrast, the 58.2% success rate with the supplementary sample
of new girls is disappointing, and analyses revealed a significant parental socioeconomic status bias associated with
these losses. To correct for this bias, female participants
have been differentially weighted in all analyses to achieve
a distribution on socioeconomic status that approximates
that observed for male participants. Because we sampled
so as to achieve roughly equal numbers of white nonHispanic, Cuban, other Hispanic, and African American participants (except where results are presented by ethnicity), the data have also been weighted to population values
with respect to ethnicity and gender.
DIAGNOSTIC ASSESSMENT
Data on the lifetime prevalence and 1-year prevalence of
psychiatric and substance use disorders were obtained
through computer-assisted personal interviews that
first large-scale community studies to estimate prevalence rates based on DSM-IV criteria. Most significantly,
half of this sample is composed of the understudied and
quite distinct Hispanic population of South Florida.
Specifically, the sample was drawn such that approximately 25% were of Cuban origin, 25% were other
Caribbean basin Hispanic, 25% were African American,
and 25% were non-Hispanic white. In addition, a substantial proportion of Hispanic participants were foreign born (44.5%), a factor that has been shown to be
relevant to mental health and substance abuse risk.8-10
Our approach in drawing this sample is in accord
with a growing consensus in the field that race is more
of a social than a biological categorization akin to ethnic status,11 and that there are important cultural variations within ethnic statuses. In an effort to minimize
the effects of such variations on results, we have distinguished Cubans from other Hispanics and limited
inclusion in the latter category to Hispanics from countries in the Caribbean basin. For the same reason, Haitians and other Caribbean black participants were
excluded in forming the African American subsample.
Because of our interest in the effects of immigration and
immigration status, we have also excluded Puerto
Ricans from the “other Hispanic” category.
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allowed estimation of DSM-IV diagnoses. Our basic instrument was theMichigan Composite International Diagnostic Interview (CIDI), which was employed in the NCS.2 The
CIDI is a fully structured interview based substantially on
the Diagnostic Interview Schedule (DIS)12 and designed to
be administered by nonclinicians trained in its use.13,14 Using the Michigan CIDI, as updated by NCS researchers to
cover DSM-IV criteria, we assessed major depression, dysthymia, generalized anxiety disorder, social phobia, panic
disorder, alcohol abuse and dependence, drug abuse and
dependence, posttraumatic stress disorder (PTSD), and antisocial personality disorder. The latter 2 modules had been
borrowed from the DIS12 for the NCS. Field trials of the original CIDI had documented good reliability and validity for
all of the CIDI diagnoses considered here.15 Evidence for
the validity of the Michigan CIDI diagnostic estimates, evaluated against structured clinical reinterviews,16 have been
reported for most NCS disorders, including affective disorders,17 anxiety disorders,18,19 addictive disorders,20,21 and
posttraumatic stress disorder.22
Along with the Michigan CIDI, our assessment instrument23 included a reliable module24 taken from the revised DIS25 to assess attention-deficit/hyperactivity disorder (ADHD) and items to allow assessment of childhood
conduct disorder. The NCS strategy of a preliminary screening process was extended to also include the lifetime use
of individual licit and illicit drugs. The goal of this extension was to reduce any falloff in reporting that might be
occasioned by learning during the course of the interview
that positive responses, and not negative responses to drug
questions, tend to be followed by a large battery of additional questions. Finally, our procedure with the PTSD
module differed from both the NCS and the ECA1 studies.
Following an extensive battery of 41 questions on major
and potentially traumatic experiences, we followed the
RESULTS
Examination of lifetime and past-year prevalence revealed that more than 60% of the sample met criteria for
1 or more study disorders at some time during their lives,
and 38% did so during the 12 months preceding the interview (Table 1 and Table 2). Childhood conduct disorder shows the highest lifetime prevalence, followed by
major depressive disorder and alcohol abuse. It is clear
from these results that the consistently observed gender
differences in affective and anxiety disorders are well established by the transition to adulthood. Females exhibit approximately double the rates observed for males
in both the lifetime and past-year data. This apparent female disadvantage is somewhat lessened when attention deficit and hyperactivity disorders are added (38.6%
for females vs 27.9% for males), and vanishes altogether
when conduct disorder and antisocial personality disorder are also considered (46.6% in females vs 45.7% in
males). This balance derives from the fact that boys are
1.75 times more likely to meet criteria for childhood conduct disorder and more than 2.5 times more likely to
qualify for the antisocial personality diagnosis. In this latter category, 71% of the females and more than 59% of
(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 59, JAN 2002
45
standard procedure of administering PTSD questions in relation to the event nominated by respondents as being the
worst. However, when, a diagnostic criterion was not met,
participants were presented with a list of the major PTSD
symptoms and asked whether they had ever experienced
any of them in relation to any other event. If a participant
responded “yes,” the event was specified and the PTSD module repeated. This is an efficient procedure that effectively
minimizes the risk of false negatives.
All interviewers held bachelors degrees and most of
them had some graduate education. They were given a total
of 7 days of training, 2 days on general interviewing techniques and procedures, and 5 days on the CIDI. Except for
the initial cohort, this training was followed by the observation of 2 interviews conducted by experienced interviewers, and by being observed while conducting interviews of
their own. The use of laptop computers assured appropriate skip patterns and greatly facilitated the reliable administration of the interview. Our standard practice was faceto-face interviewing in the respondent’s home or in our
research offices as the respondent chose. However, telephone interviews using previously mailed response booklets were employed for those who were away at university
or who had moved elsewhere in the contiguous United
States. Approximately 30% of the interviews were conducted by telephone. There is abundant evidence that inperson and telephone interviews yield comparable data.26-28
Analyses were conducted using SPSS 10 (Statistical Products and Service Solutions 10; SPSS Inc, Chicago, Ill). As noted
above, data were weighted to correct for an underrepresentation of girls with higher socioeconomic status and to reflect
population distributions on gender and ethnicity. The
CROSSTABS and DESCRIPTIVES programs of the SPSS software package were used to compute ␹2 tests of the significance
of prevalence differences across gender and ethnicity.
the males indicated that the behaviors involved were
caused by their use of drugs or alcohol. Thus, not only
are females much less likely to meet antisocial personality diagnostic criteria, those who do are more likely to
attribute their behavior to substance use problems. When
drug and alcohol disorders are also included, the prevalence of all study disorders combined is higher for males
than for females (62.9% vs 58.5%, respectively). However, this difference is not statistically significant.
In general, 12-month prevalence rates correspond
rather closely with lifetime rates, as might be expected
given the youth of the cohort studied (Table 2). An important point in connection with these data is the tendency for disorders to be highly recurrent or persistent.
For example, our analyses (not shown) reveal that only
22 % of 12-month prevalent cases of major depression
turn out to be first onsets. When these cases are excluded from both the lifetime and 12-month prevalence
estimates, the data indicate that 61% of those with a history of major depression experienced a recurrent or continuing episode of that disorder in the preceding year.
Even in the case of alcohol dependence and marijuana
dependence, in which 59% and 47%, respectively, of the
12-month prevalent cases were new onsets, approximately half of those with a history of alcohol or mariWWW.ARCHGENPSYCHIATRY.COM
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©2002 American Medical Association. All rights reserved.
Table 1. Lifetime Prevalence of Psychiatric Disorders by Gender*
Major depressive episode
Dysthymia
Any affective disorder
Generalized anxiety disorder
Social phobia
Panic disorder
PTSD
Any anxiety disorder
HD
AD
ADHD
Any psychiatric disorder 1†
Conduct disorder
Antisocial personality disorder
Antisocial not drug related
Any psychiatric disorder 2‡
Alcohol abuse
Alcohol dependence
Marijuana abuse
Marijuana dependence
Other drug abuse or dependence
Any substance abuse or dependence
Any study disorder
Total
(N = 1803)
Males
(n = 952)
Females
(n = 851)
Gender Comparison
P Value
17.4 (0.9)
0.5 (0.2)
17.7 (0.9)
1.4 (.03)
2.5 (0.6)
2.1 (0.3)
11.7 (0.8)
15.2 (0.9)
4.6 (0.5)
4.8 (0.5)
1.8 (0.3)
33.4 (1.1)
24.3 (1.0)
14.6 (0.8)
9.2 (1.2)
46.2 (1.2)
16.2 (1.3)
8.9 (0.9)
11.8 (1.3)
11.7 (0.7)
10.2 (0.7)
36.4 (1.1)
60.7 (1.1)
12.4 (1.1)
0.6 (0.2)
12.3 (1.1)
0.2 (0.2)
2.1 (0.5)
0.8 (0.3)
7.7 (0.9)
9.7 (1.0)
6.0 (0.8)
4.7 (0.7)
2.6 (0.5)
27.9 (1.5)
31.0 (1.6)
21.1 (1.4)
12.5 (2.1)
45.7 (1.7)
21.8 (1.7)
9.2 (1.4)
15.3 (1.9)
14.8 (1.2)
12.3 (1.1)
44.3 (1.7)
62.9 (1.6)
23.1 (1.4)
0.5 (0.2)
23.1 (1.4)
2.6 (0.5)
2.8 (1.1)
3.4 (0.6)
15.6 (1.2)
20.6 (1.3)
3.3 (0.6)
4.9 (0.7)
1.0 (0.3)
38.6 (1.6)
17.7 (1.3)
8.3 (0.9)
5.9 (1.2)
46.6 (1.7)
10.6 (2.0)
8.8 (0.9)
8.5 (1.6)
8.6 (0.9)
8.2 (0.9)
28.7 (1.5)
58.5 (1.6)
⬍.001
...
⬍.001
⬍.001
...
⬍.001
⬍.001
⬍.001
⬍.01
...
⬍.01
⬍.001
⬍.001
⬍.001
⬍.001
...
⬍.001
...
⬍.001
⬍.001
⬍.01
⬍.001
...
*All data are given as percentage (SE). All tests are ␹2, and data are weighted to reflect the population distribution of gender and ethnicity. PTSD indicates
posttraumatic stress disorder; HD, hyperactivity disorder; AD, attention-deficit disorder; ADHD, attention-deficit/hyperactivity disorder; and ellipses, not applicable.
†Indicates any psychiatric disorder (excluding conduct and antisocial personality disorder) and drug abuse/dependence.
‡Indicates any psychiatric disorder (including conduct and antisocial personality disorder) excluding drug abuse/dependence.
Table 2. Twelve-Month Prevalence of Psychiatric Disorders by Gender*
Major depressive episode
Dysthymia
Any affective disorder
Generalized anxiety disorder
Social phobia
Panic disorder
PTSD
Any psychiatric disorder
Alcohol abuse
Alcohol dependence
Marijuana abuse
Marijuana dependence
Other drug abuse or dependence
Any substance abuse or dependence
Any study disorder†
Total
(N = 1803)
Males
(n = 952)
Females
(n = 851)
Gender
Comparison
11.6 (0.8)
0.1 (.06)
11.3 (0.8)
0.9 (0.2)
1.5 (0.3)
1.6 (0.3)
8.4 (0.7)
11.0 (0.7)
10.8 (0.7)
5.6 (0.5)
6.5 (0.6)
7.0 (0.6)
5.1 (0.5)
24.7 (1.0)
38.0 (1.2)
7.2 (0.9)
0.1 (0.1)
7.1 (0.9)
0.2 (0.1)
1.4 (0.4)
0.4 (0.2)
5.8 (0.8)
7.4 (0.9)
15.0 (1.2)
6.0 (0.8)
9.8 (1.0)
8.7 (0.9)
6.1 (0.8)
31.5 (1.6)
39.9 (1.7)
15.8 (1.2)
0
15.5 (1.2)
1.6 (0.4)
1.5 (0.4)
2.7 (0.5)
11.0 (1.0)
14.6 (1.2)
6.6 (0.8)
5.2 (0.7)
3.4 (0.6)
5.3 (0.7)
4.2 (0.7)
17.1 (1.3)
36.0 (1.6)
⬍.001
...
⬍.001
⬍.001
...
⬍.001
⬍.001
⬍.001
⬍.001
...
⬍.001
⬍.01
...
⬍.001
...
*All data are given as percentage (SE). All tests are ␹2, and data are weighted to reflect the population distribution of gender and ethnicity and to correct for
socioeconomic status bias among girls. PTSD indicates posttraumatic stress disorder; ellipses, not applicable.
†Indicates any study disorder excluding conduct disorder, antisocial personality, attention-deficit, hyperactivity, and attention-deficit/hyperactivity
disorder.
juana dependence had a recurrent or continuing episode in the year prior to interview.
Lifetime and 12-month prevalence rates by ethnicity and nativity are presented in Table 3 and Table 4.
In examining these contrasts, we focus primarily on differences between African American and non-Hispanic
white participants and between US-born and foreignborn participants within the Cuban and “other His(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 59, JAN 2002
46
panic” subgroups. Although when Axis I lifetime psychiatric disorders are considered together (“Any
psychiatric disorder 1” in Table 3) no statistically significant differences are observed across ethnicity or nativity, many notable variations are evident for specific diagnoses. Compared with non-Hispanic white participants,
African Americans are at a substantially lower risk for all
study disorders considered together and for depressive
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Table 3. Lifetime Prevalence of Psychiatric Disorders by Ethnicity and Nativity in 1785 Participants*
Other Hispanics
Cubans
Major depressive episode
Dysthymia
Any affective disorder
Generalized anxiety disorder
Social phobia
Panic disorder
PTSD†
Any anxiety disorder
HD†
AD
ADHD combined
Any psychiatric disorder 1‡
Conduct disorder†
Antisocial personality disorder
Antisocial not drug related
Any psychiatric disorder 2§†
Alcohol abuse
Alcohol dependence
Marijuana abuse㛳
Marijuana dependence㛳
Other drug abuse or dependence㛳
Any substance abuse or dependence㛳†
Any study disorder†
White
Non-Hispanic
(n = 463)
African
American
(n = 434)
US Born
(n = 295)
Foreign Born
(n = 140)
US Born
(n = 198)
Foreign Born
(n = 255)
20.0 (1.8)¶
0.2 (0.02)
19.8 (1.8)¶
1.6 (0.6)
2.2 (0.7)
2.8 (0.7)
9.6 (1.3)#
14.6 (1.6)
4.4 (0.9)
5.6 (1.0)
1.2 (0.5)
33.3 (2.1)
22.2 (1.9)
11.7 (1.4)¶
4.8 (2.4)**
45.5 (2.2)
22.2 (1.9)**
15.8 (1.6)**
18.4 (2.4)**
14.2 (1.6)**
14.3 (1.6)**
49.7 (2.3)¶
67.5 (2.1)**
12.8 (1.6)
0.7 (0.4)
12.8 (1.7)
1.0 (0.5)
1.4 (1.8)
1.2 (0.5)
14.3 (1.7)
15.7 (1.8)
4.5 (1.0)
4.1 (0.9)
1.7 (0.6)
31.2 (2.3)
26.7 (2.2)
18.6 (1.9)
15.3 (2.4)
46.8 (2.5)
6.7 (2.4)
4.0 (0.9)
6.7 (1.9)
7.1 (1.2)
2.4 (0.8)
20.4 (2.0)
53.4 (2.5)
19.0 (2.3)
1.7 (0.7)
19.7 (2.4)
1.0 (0.6)
2.7 (0.9)
1.0 (0.6)
8.4 (1.6)
11.4 (1.9)
3.7 (1.1)#
4.0 (1.2)
1.0 (0.6)
30.8 (2.7)
21.1 (2.4)
11.7 (1.8)
6.4 (2.9)
41.5 (2.9)
22.0 (3.6)
7.0 (1.5)
15.7 (2.2)
14.7 (2.1)
16.7 (2.2)
44.5 (2.9)
60.9 (2.9)
17.8 (3.4)
0
17.0 (3.4)
.8 (0.6)
3.8 (1.7)
3.0 (1.5)
8.9 (2.6)
14.1 (3.2)
8.3 (2.5)
3.8 (1.8)
1.5 (1.1)
31.1 (4.1)
24.1 (3.8)
12.8 (2.9)
6.8 (4.7)
44.4 (4.4)
18.5 (3.3)
9.6 (2.6)
11.1 (6.7)
11.9 (2.7)
14.1 (3.1)
37.8 (4.3)
59.3 (4.4)
18.3 (2.8)
0.5 (0.5)
18.5 (2.9)
2.6 (1.1)
2.1 (0.9)
3.6 (1.3)
15.9 (2.7)#
19.9 (2.9)#
3.1 (1.2)
3.6 (1.3)
4.6 (1.6)#
36.9 (3.0)
33.5 (3.4)¶
18.5 (2.7)
12.8 (3.8)
53.6 (3.0)
21.0 (4.9)
10.2 (2.1)
15.3 (4.9)¶
17.3 (2.7)¶
12.3 (2.4)¶
46.4 (3.6)¶
71.3 (3.3)**
18.0 (2.4)
0
17.6 (2.4)
1.2 (0.7)
3.6 (1.1)
2.4 (0.9)
9.4 (1.8)
13.8 (2.2)
5.1 (1.4)
6.3 (1.6)
1.6 (0.8)
33.9 (2.9)
22.4 (2.2)
16.1 (2.3)
8.7 (3.6)
44.9 (3.2)
15.0 (4.2)
9.8 (4.0)
7.1 (3.9)
9.4 (1.9)
7.8 (1.7)
32.7 (2.9)
56.5 (3.1)
*All data are given as percentage (SE). All tests are ␹2. Eighteen participants were excluded from this analysis because they belonged to other ethnic groups.
Data are weighted to correct the underrepresentation of girls with higher socioeconomic status. PTSD indicates posttraumatic stress disorder; HD, hyperactivity
disorder; AD, attention-deficit disorder; and ADHD, attention-deficit/hyperactivity disorder.
†US-born Hispanic subjects differed from foreign-born Cuban subjects; P⬍.05.
‡Indicates any psychiatric disorder excluding conduct and antisocial personality disorders, and drug abuse or dependence.
§Indicates any psychiatric disorder including conduct and antisocial personality disorders, and excluding drug abuse or dependence.
㛳US-born Cuban subjects differed from foreign-born Hispanic subjects; P⬍.01.
¶P⬍.01.
#P⬍.05.
**P⬍.001.
Table 4. Twelve-Month Prevalence of Psychiatric Disorders by Ethnicity and Nativity in 1785 Participants*
Other Hispanics
Cubans
Major depressive episode
Dysthymia
Any affective disorder
Generalized anxiety disorder
Social phobia
Panic disorder
PTSD†
Any anxiety disorder
Alcohol abuse
Alcohol dependence
Marijuana abuse‡
Marijuana dependence‡
Other drug abuse/dependence†
Any substance abuse/dependence†‡
Any study disorder§†
White
Non-Hispanic
(n = 463)
African
American
(n = 434)
US Born
(n = 295)
Foreign Born
(n = 140)
US Born
(n = 198)
Foreign Born
(n = 255)
13.1 (1.5)㛳
0
13.0 (1.5)㛳
1.0 (0.4)
1.6 (0.6)
2.4 (0.7)¶
7.1 (1.2)¶
11.0 (1.4)
15.4 (1.7)#
11.2 (1.4)#
8.6 (1.3)㛳
10.0 (1.4)㛳
8.0 (1.2)#
36.5 (2.2)#
47.5 (2.3)#
8.2 (1.4)
0.2 (0.2)
8.1 (1.4)
0.5 (0.3)
1.0 (0.5)
0.7 (0.4)
10.5 (1.5)
11.6 (1.6)
5.0 (1.0)
2.1 (0.7)
4.3 (1.0)
5.2 (1.1)
0.7 (0.3)
14.3 (1.7)
29.0 (2.2)
12.4 (1.9)
0
12.0 (1.9)
1.0 (0.6)
2.0 (0.9)
0.7 (0.5)
6.4 (1.4)
9.0 (1.7)
14.0 (2.1)
3.7 (1.2)
9.0 (1.7)
7.7 (1.6)
7.7 (1.6)
28.1 (2.7)
40.1 (2.9)
7.8 (2.4)
0
7.4 (2.4)
0.8 (0.6)
1.5 (0.9)
2.3 (1.3)
7.4 (2.4)
10.4 (2.8)
14.8 (3.0)
6.7 (2.1)
5.9 (2.1)
8.9 (2.4)
10.1 (2.7)
29.6 (3.9)
40.0 (4.3)
13.6 (2.5)
0
13.3 (2.5)
1.5 (0.8)
1.0 (0.6)
2.6 (1.1)
9.8 (2.2)
12.3 (2.4)
11.7 (2.3)
5.1 (1.5)
9.7 (2.2)㛳
10.2 (2.2)㛳
5.1 (1.5)
29.7 (3.3)㛳
43.1 (3.6)¶
11.6 (2.0)
0
11.4 (2.0)
0.8 (0.6)
2.4 (0.9)
1.2 (0.7)
7.1 (1.6)
10.2 (1.8)
9.4 (1.8)
5.9 (1.5)
3.9 (1.3)
3.5 (1.2)
3.5 (1.2)
19.3 (2.5)
32.7 (3.0)
*All data are given as percentage (SE). All tests were ␹2. Eighteen participants were excluded from this analysis because they belonged to other ethnic groups.
Data are weighted to correct the underrepresentation of girls with higher socioeconomic status.
†US-born Hispanic participants differed from foreign-born Cuban participants.
‡US-born Cuban participants differed from foreign-born Hispanic participants.
§Excludes conduct, antisocial personality, attention-deficit, hyperactivity, and attention-deficit/hyperactivity disorders.
㛳P⬍.01.
¶P⬍.05.
#P⬍.001.
(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 59, JAN 2002
47
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Table 5. Comorbidity Among Persons With Lifetime Psychiatric and Substance Disorders by Ethnicity and Nativity*
Other Hispanics
Cubans
No. of
Lifetime
Disorders
Proportion
of Sample
All
(N = 1785)
0
1
2
3
ⱖ4
39.3
25.5
11.7
10.4
13.1
...
41.9
19.3
17.1
21.8
0
1
2
ⱖ3
53.8
22.3
13.4
10.5
...
48.3
28.9
12.8
0
1
2
3
61.6
21.2
10.6
6.7
...
55.0
27.6
17.4
White
Non-Hispanic
(n = 463)
African
American
(n = 434)
US Born
(n = 295)
Foreign Born
(n = 140)
US Born
(n = 198)
Foreign Born
(n = 255)
...
42.0
15.9
21.6
20.5
...
34.7
19.6
20.9
24.8
...
45.2
17.8
12.8
24.2
Proportion of Lifetime Psychiatric Disorders
...
...
...
50.3
49.3
52.9
28.4
31.0
24.3
21.1
19.7
22.8
...
49.2
27.7
23.1
...
39.1
33.0
27.9
...
48.4
27.0
24.6
Proportion of Lifetime Substance Use Disorders
...
...
...
50.2
74.4
52.6
29.7
19.8
23.3
20.1
5.8
24.1
...
49.0
27.5
23.5
...
51.1
34.4
14.5
...
59.5
31.0
9.5
Proportion of All Lifetime Disorders
...
...
...
38.7
48.8
39.6
21.4
22.3
16.8
16.0
15.4
19.2
23.9
13.5
24.2
*Data are weighted to correct the underrepresentation of girls with higher socioeconomic status.
disorder. They are also at dramatically lower risk with
respect to the abuse of or dependence on substances, regardless of which substance-abuse or dependence category is considered. Among our African American sample,
elevated lifetime prevalence is observed only with respect to PTSD. A similarly high occurrence of PTSD is
found only among US-born “other Hispanics.”
Comparisons across nativity among Cuban respondents revealed only one significant difference. Within this
subgroup, the foreign-born respondents reported significantly higher levels of hyperactivity disorder than their
US-born counterparts. In contrast, nativity is associated
with a range of prevalence differences in the “other Hispanic” group. Higher rates were found among the USborn Hispanics on substance use disorders, conduct disorder, ADHD, and PTSD.
Because of interest in the possible significance of nativity as a gross index of acculturation, we also compared prevalence rates observed for US-born Cubans and
US-born “other Hispanics” with those for foreign-born
respondents of the opposite group. Statistically significant contrasts are indicated by superscript letters attached where relevant to each disorder listed. Except for
PTSD, all of the differences found involved disorders
characterized by externalizing symptoms. Importantly,
in every instance, US-born respondents were shown to
be at greater risk than those in the foreign-born comparison group. The 12-month prevalence data presented in Table 4 present variations across ethnicity and
nativity that are substantially in accord with those found
for lifetime prevalence.
Table 5 presents the prevalence of comorbidity in
this community population, where comorbidity is defined as qualifying for 2 or more diagnoses throughout
one’s lifetime. The middle and lower portions of Table 5
report this form of comorbidity when psychiatric and substance use disorders are considered separately. As shown
in the first column of the top portion of the table, 39%
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48
of respondents had never experienced any of the disorders assessed, about 25% had experienced only 1 disorder, 12% had 2 disorders, 10% had 3, and more than 13%
qualified for 4 or more diagnoses. From the second column, it can be seen that 42% of all lifetime disorders occurred in individuals whose histories included only that
single disorder. In other analyses (not shown) we found
that 62% of 12-month disorders were comorbid.
The patterns of comorbidity that are revealed when
only psychiatric disorders are considered (middle portion of Table 5) correspond quite closely with those for
all disorders. However, differences appear in analyses restricted to lifetime substance disorders. Not only are African Americans dramatically less likely to meet criteria
for substance abuse or dependence (Table 3), those who
do are significantly more likely than others to qualify for
only a single substance use disorder. Somewhat lower rates
of substance use disorder comorbidity are also found
among foreign-born “other Hispanics,” who, like the African American group, are comparatively unlikely to have
experienced 3 or more substance use disorders.
Comorbidity across substance and psychiatric disorders was also specifically examined. A total of 154 individuals (8.5% of the sample) met criteria for at least 1
substance use disorder and 1 psychiatric disorder. In
52.4% of these instances, the psychiatric disorder was reported to have occurred first; in 23.5% the substance disorder was first; and in 24%, the onsets of both types of
disorder took place in the same year. It thus seems that
psychiatric disorder is a better predictor of a subsequent substance disorder than is a substance use disorder a predictor of a subsequent psychiatric disorder.
COMMENT
Despite the youth of this cohort, or perhaps because of
it, more than 60% met criteria for 1 or more study disorders during their lives. In the vast majority of inWWW.ARCHGENPSYCHIATRY.COM
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stances, the first onset of disorder occurred during the
middle school and early high school years, and in 58%
of the cases, detected disorders were comorbid. These findings indicate that there is a substantial presence of psychiatric and substance use disorders in middle and high
school classrooms in South Florida. Thus, it cannot be
assumed that study or intervention participants have no
history of having a disorder just because they are young.
This is a point that may not be well understood by many
researchers and service providers.
The substantial level of comorbidity observed here
falls well short of that reported by the NCS that involved participants up to 55 years of age. This ageassociated contrast provides support for the argument
that efforts might be usefully directed toward the primary prevention of secondary disorders.29 Because psychiatric disorders are more likely to precede the onset
of substance use disorders than the reverse, it can be argued that efforts to prevent the occurrence of drug and
alcohol problems should focus substantial attention on
young persons who are experiencing or who have experienced a psychiatric disorder. Additional analyses (not
shown) made clear that this increased risk for substance
abuse or dependence applies to those with prior episodes of anxiety and/or affective disorders, whether or
not the co-occurrences of conduct, antisocial personality, attention-deficit, and/or hyperactivity disorders are
controlled.
Although expected gender differences in depressive and anxiety disorders are clearly confirmed in this
young adult sample, gender equivalence in total prevalence was observed without the inclusion of substance
diagnoses (“Any psychiatric disorder 2” in Table 1). This
rather unique finding results from higher rates of hyperactivity disorder, ADHD, and conduct disorder among
males—diagnoses that have not uniformly been assessed in prior investigations. When substance use disorders were also considered, the prevalence of “any study
disorder” (Table 1) was 62.9% among males compared
with 58.5% among females. The idea that women are at
greater risk for mental disorders is not supported in these
results, whether or not substance use disorders are taken
into account.
The presence of Hispanics of differing nativity in
this study allowed at least a gross estimation of the significance of acculturation as a risk or protective factor
with respect to psychiatric and substance use disorders.
Results obtained from this same cohort during the early
adolescent years revealed lower rates of substance use
among foreign-born compared with US-born participants,8,30 as well as better mental health.31 Similarly,
Vega et al9 found lower rates of psychiatric disorders
among Mexican immigrants than among their US-born
counterparts. The findings in this study, with respect to
the “other Hispanic” group but not within the subsample of Cuban heritage, substantially concur with
these prior reports. While a lower prevalence was found
among foreign-born “other Hispanics” for several psychiatric diagnoses, the more marked differences
occurred for the substance use disorders. These latter
contrasts were also observed in comparisons of this
group with US-born Cuban immigrants.
(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 59, JAN 2002
49
Despite substantial research examining these differences,9,32 compelling explanations for why greater time
spent in the United States is associated with increased
mental health and substance abuse risk8,10 remain elusive. In this connection, it should be noted that none of
the foreign-born participants in this cohort are recent immigrants, having come to the United States either before or at the time of entry into middle school. Thus, differences with their US-born counterparts seem to be
persistent in nature. Evidence bearing on these issues will
be presented in subsequent publications.
When psychiatric disorders other than conduct and
antisocial personality disorders were considered together, no significant ethnic differences emerged; however, important differences in prevalence were observed
for individual diagnoses and when all study disorders
were considered together. Consistent with results from
the NCS,2 African Americans have significantly lower rates
of affective disorders, substance use disorders, and overall lifetime comorbidity than non-Hispanic white participants. However, contrary to the same study’s report
of no instances in which either lifetime or active prevalence was significantly higher among African American
than white participants, we found significantly higher lifetime and 12-month prevalence of PTSD in the African
American subgroup. This finding seems to be in accord
with the results of Breslau et al.33
The limitations of this investigation include those
that characterize prior studies that have derived diagnoses from a single structured interview that did not involve clinical judgment. Since the data are crosssectional, lifetime prevalence estimates rely entirely on
retrospective recall. While the young age of this cohort
presumably minimizes recall problems, such problems
remain a concern. Collectively, these measurement concerns require that the prevalence results reported be
viewed as only estimates of the rates at which symptomatic experiences matching diagnostic criteria occur within
the populations studied.
Accepted for publication June 26, 2001.
This study was supported by grant R01 DA10772 from
the National Institute on Drug Abuse, Bethesda, Md.
Corresponding author: R. Jay Turner, PhD, Life Course
and Health Research Center, Florida International University, University Park Campus, Deuxieme Maison (DM 243),
Miami, FL 33199 (e-mail: [email protected]).
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