1. Epidemiology of Comorbid Psychiatric and Addictive Disorders Kathleen Ries Merikangas, Ph.D. Senior Investigator APA, May 4, 2004

2. Kevin P. Conway, Ph.D. Deputy Branch Chief Epidemiology Research Branch

4. Goals 1.Identify key patterns emerging from epidemiologic data on drug/mental disorder comorbidity 2.Briefly discuss implications of a heterogeneous phenotype for classification, treatment, and genetics research

5. Goal 1 Key patterns from epidemiologic data  Comorbidity is the rule rather than the exception  Cross-cultural findings show that the magnitude of comorbidity is more similar than are the differences in baseline prevalence  Risk for drug dependence > drug abuse  Risk varies by mental disorder (Anxiety < Mood < ASPD)  Risk varies by gender (female > male)  Risk varies somewhat by specific drug disorder and number of drug disorders

6. Lifetime Prevalence and Odds Ratios of Mental Disorders by Substance Use Disorder: ECA Alcohol Drug Comorbid Disorder %O.R.%O.R. Any mental36.62.353.14.5 Schizophrenia3.83.36.86.2 Affective13.41.926.44.7 Anxiety19.41.528.32.5 Antisocial14.321.017.813.8 (Regier et al., JAMA 264:2511-2518, 1990)

7. Goal 1 Key patterns from epidemiologic data  Comorbidity is the rule rather than the exception  Cross-cultural findings show that the magnitude of comorbidity is more similar than are the differences in baseline prevalence  Risk for drug dependence > drug abuse  Risk varies by mental disorder (Anxiety < Mood < ASPD)  Risk varies by gender (female > male)  Risk varies somewhat by specific drug disorder and number of drug disorders

8. Lifetime Prevalence of Drug Dependence and Mood Disorder International Consortium on Psychiatric Epidemiology (Merikangas et al., Addictive Behaviors, 1998)

9. Lifetime Comorbidity of Drug Dependence and Mood Disorder International Consortium on Psychiatric Epidemiology (Merikangas et al., Addictive Behaviors, 1998)

10. Population Attributable Risk of Drug Dependence due to Prior Mental Disorders: International Consortium on Psychiatric Epidemiology Kessler et al., Psychiatria Fennica, 32 (suppl 2): 62-79, 2001

11. Lifetime Prevalence of Mood Disorder among Puerto Rican Probands with Drug Dependence: Preliminary Results from a Migrant Family Study (Conway, Swendsen, Canino, & Merikangas, in preparation) %

12. Goal 1 Key patterns from epidemiologic data  Comorbidity is the rule rather than the exception  Cross-cultural findings show that the magnitude of comorbidity is more similar than are the differences in baseline prevalence  Risk for drug dependence > drug abuse  Risk varies by mental disorder (Anxiety < Mood < ASPD)  Risk varies by gender (female > male)  Risk varies somewhat by specific drug disorder and number of drug disorders

13. Lifetime Comorbidity by Drug Abuse and Dependence: ECA O.R.AbuseDependence Any Anxiety2.32.6 Phobia2.12.2 Panic1.44.4 OCD3.23.6 Any Mood4.14.4 Bipolar5.28.3 MDD3.33.7 Dysthymia3.63.6 Antisocial5.215.6 (Regier et al., JAMA 264:2511-2518, 1990.)

14. (median odds ratio across sites) UseAbuseDependence Anxiety1.92.54.0 Mood2.23.13.5 Lifetime Anxiety and Mood Comorbidity by Drug Use, Abuse, and Dependence: International Consortium on Psychiatric Epidemiology

15. Goal 1 Key patterns from epidemiologic data  Comorbidity is the rule rather than the exception  Cross-cultural findings show that the magnitude of comorbidity is more similar than are the differences in baseline prevalence  Risk for drug dependence > drug abuse  Risk varies by mental disorder (Anxiety < Mood < ASPD)  Risk varies by gender (female > male)  Risk varies somewhat by specific drug disorder and number of drug disorders

16. Lifetime Comorbidity by Specific Drug Use Disorder: NESARC AnxietyMoodASPD O.R.MFMFMF Any Drug3.02.93.84.18.117.1 Marijuana2.82.73.53.87.514.0 Cocaine3.02.74.04.27.518.0 Amphetamine3.74.14.65.69.216.9 Hallucinogen3.24.05.06.510.816.9 Opioid3.34.25.27.59.916.1 Sedative4.14.25.57.19.117.6 Tranquilizer3.86.85.67.111.220.3 (Conway, Compton, & Grant, in preparation)

17. Lifetime Mood and/or Anxiety Comorbidity by Multiple Drug Use Disorders: NESARC (Conway, Compton, & Grant, in preparation)

18. Goal 2 1.Identify key patterns emerging from epidemiologic data on drug/mental disorder comorbidity 2.Briefly discuss implications of a heterogeneous phenotype for classification, treatment, and genetics research

19. The Phenotype “Probably the single most important aspect of studies of complex diseases is the phenotype, which may well be multidimensional.” P. Michael Conneally, 2002 ASHG Presidential Address

20. Pathways to Substance Disorders through Psychopathology: Yale Family Study (Relative Risk) AgeAge151520202525551010ADHDADHD ConductConduct ConductConduct BipolarBipolar 6.06.0 5.05.04.04.05.05.0AnxietyAnxietyDepressionDepression 2.02.0 PhobiaPhobia

21. Relative Risk of Daily Smoking by Preexisting Psychiatric Disorders (NCS) Any ActivePast MDD1.51.60.6 Dysthymia1.61.61.5 Agoraphobia1.31.40.1 GAD1.92.1ne Simple Phobia1.61.50.9 Social Phobia1.51.32.8 Panic Disorder0.90.91.7 PTSD2.12.02.5 (Breslau, Novak, & Kessler, Biol Psychiatry 2004)

22. Drug abuse = 0 Drug abuse = 1 Risk Conventional Definition: Dichotomous Disorder

23. Antisocial/Substance Biological Diathesis Langbehn et al., DAD, 69: 151-167, 2003 Age of Onset of Drug Problems