Mental Health and Substance Use

"The 2020 NSDUH provided estimates of any mental illness (AMI) and serious mental illness (SMI) for adults aged 18 or older. Adults aged 18 or older were classified as having AMI if they had any mental, behavioral, or emotional disorder in the past year of sufficient duration to meet DSM-IV criteria (excluding developmental disorders and SUDs).^18,79

"Adults who were classified as having AMI were classified as having SMI if they had any mental, behavioral, or emotional disorder that substantially interfered with or limited one or more major life activities. Statistical prediction models that were developed using clinical interview data from a subset of NSDUH adult respondents in 2008 to 2012 were used to classify whether respondents in the 2008 to 2020 adult samples had AMI or SMI in the past year.⁸⁰

"As noted previously, a set of break-off analysis weights was developed for adults’ mental health data for 2020. Estimates of AMI and SMI for 2020 used these break-off analysis weights.

"Among adults aged 18 or older in 2020, 21.0 percent (or 52.9 million people) had AMI in the past year (Table A.29B). The percentage was highest among young adults aged 18 to 25 (30.6 percent or 10.2 million people), followed by adults aged 26 to 49 (25.3 percent or 25.7 million people), then by adults aged 50 or older (14.5 percent or 16.9 million people).

"Serious Mental Illness among Adults in the Past Year

"Among adults aged 18 or older in 2020, 5.6 percent (or 14.2 million people) had SMI in the past year (Figure 32). Consistent with the age group pattern for AMI, the percentage of adults with SMI was highest among young adults aged 18 to 25 (9.7 percent or 3.3 million people), followed by adults aged 26 to 49 (6.9 percent or 7.0 million people), then by adults aged 50 or older (3.4 percent or 4.0 million people)."

"Among the 9.5 million adults aged 18 or older in 2019 who had a co-occurring SUD [Substance Use Disorder] and AMI [Any Mental Illness] in the past year (2019 DT 10.6), 48.6 percent (or 4.6 million people) received either substance use treatment at a specialty facility or mental health services in the past year, 38.7 percent (or 3.7 million people) received only mental health services, and 7.8 percent (or 742,000 people) received both substance use treatment at a specialty facility and mental health services (Figure 80 and 2019 DT 10.27). These percentages in 2019 were similar to the percentages in 2015 to 2018.

"Among adults aged 18 or older in 2019 who had a co-occurring SUD and AMI in the past year, 1.9 percent (or 182,000 people) received only substance use treatment at a specialty facility (2019 DT 10.27). This percentage in 2019 was lower than the percentages in 2015 and 2017 but was similar to the percentages in 2016 and 2018.

"Aged 18 to 25
"Among the 2.6 million young adults aged 18 to 25 in 2019 who had a co-occurring SUD and AMI in the past year (2019 DT 10.6), 43.3 percent (or 1.1 million people) received either substance use treatment at a specialty facility or mental health services in the past year, and 36.7 percent (or 941,000 people) received only mental health services (2019 DT 10.28). These percentages in 2019 were higher than the percentages in 2015, but they were similar to the percentages in 2016 to 2018.

"Also among young adults aged 18 to 25 in 2019 who had a co-occurring SUD and AMI in the past year, 5.0 percent (or 130,000 people) received both substance use treatment at a specialty facility and mental health services, which was similar to the percentages in 2015 to 2018 (2019 DT 10.28). Among young adults in 2019 who had a co-occurring SUD and AMI in the past year, 1.4 percent (or 35,000 people) received only substance use treatment at a specialty facility. This percentage in 2019 was lower than the percentages in 2015 to 2017 but was similar to the percentage in 2018.

"Aged 26 or Older
"Among the 7.0 million adults aged 26 or older⁸¹ in 2019 who had a co-occurring SUD and AMI in the past year (2019 DT 10.6), 50.5 percent (or 3.5 million people) received either substance use treatment at a specialty facility or mental health services in the past year, 39.5 percent (or 2.7 million people) received only mental health services, and 8.8 percent (or 613,000 people) received both substance use treatment at a specialty facility and mental health services (2019 DT 10.29). These percentages in 2019 were similar to the percentages in 2015 to 2018. Among these adults in 2019 who had a co-occurring SUD and AMI in the past year, 2.1 percent (or 147,000 people) received only substance use treatment at a specialty facility. This percentage was lower than the percentages in 2015 and 2017 but was similar to the percentages in 2016 and 2018."

"Among the 3.6 million adults aged 18 or older in 2019 who had a co-occurring SUD and SMI in the past year (2019 DT 10.6), 66.6 percent (or 2.4 million people) received either substance use treatment at a specialty facility or mental health services in the past year, 52.0 percent (or 1.9 million people) received only mental health services, 12.7 percent (or 452,000 people) received both substance use treatment at a specialty facility and mental health services, and 1.9 percent (or 68,000 people) received only substance use treatment at a specialty facility (Figure 81 and 2019 DT 10.27). These percentages in 2019 were similar to the percentages in 2015 to 2018.

"Aged 18 to 25
"Among the 958,000 young adults aged 18 to 25 in 2019 who had a co-occurring SUD and SMI in the past year (2019 DT 10.6), 60.5 percent (or 577,000 people) received either substance use treatment at a specialty facility or mental health services in the past year, 7.0 percent (or 67,000 people) received both substance use treatment at a specialty facility and mental health services, and 2.0 percent (or 19,000 people) received only substance use treatment at a specialty facility (2019 DT 10.28). These percentages in 2019 were similar to the percentages in 2015 to 2018.

"Also among young adults aged 18 to 25 in 2019 who had a co-occurring SUD and SMI in the past year, 51.4 percent (or 491,000 people) received only mental health services (2019 DT 10.28). This percentage in 2019 was higher than the percentage in 2015, but it was similar to the percentages in 2016 to 2018.

"Aged 26 or Older
"Among the 2.6 million adults aged 26 or older in 2019 who had a co-occurring SUD and SMI in the past year (2019 DT 10.6),81 68.9 percent (or 1.8 million people) received either substance use treatment at a specialty facility or mental health services in the past year, 52.2 percent (or 1.4 million people) received only mental health services, 14.8 percent (or 385,000 people) received both substance use treatment at a specialty facility and mental health services, and 1.9 percent (or 48,000 people) received only substance use treatment at a specialty facility (2019 DT 10.29). These percentages in 2019 were similar to the percentages in 2015 to 2018."

"In 2012–2013, the NESARC-III [National Epidemiologic Survey on Alcohol and Related Conditions–III], a large national survey of US adults, assessed 12-month and lifetime disorders, including DUDs, diagnosed according to the new DSM-5. The NESARC-III used rigorous survey and field methods and incorporated measures of functioning and detailed assessments of treatment use. The NESARC-III results indicate that the prevalence rates of 12-month and lifetime DSM-5 DUD were 3.9% and 9.9%, respectively, representing approximately 9,131,250 and 23,310,135 US adults, respectively. Thus, a large number of US adults were affected by DUDs, as were an unmeasured additional number of individuals in the families and social networks of those with the disorder. Further, DSM-5 DUD was characterized by considerable psychiatric comorbidity and disability, thus indicating a serious condition. Associations with comorbidity and disability increased as the severity of DSM-5 DUD increased, indicating validity and utility for the DSM-5 DUD severity metric. Moreover, consistent with previous studies, DUDs largely went untreated, even among those with severe disorders, indicating that lack of treatment use continues to be a substantial problem."

"States reported a total of 1,248,599 individuals with co-occurring mental health and substance use disorders aged 12 years and older who were served in the 2019 reporting period, accounting for 20 percent of all individuals served during this period.

"Mental health diagnoses for individuals with co-occurring mental health and substance use disorders aged 12 and older who were served in the 2019 reporting period differed somewhat by gender, age group, race, ethnicity, living arrangements, employment, not in labor force details, service setting, and timing of admission. Mental health diagnoses for this cohort were largely similar across SMI/SED [Serious Mental Illness / Serious Emotional Disturbance] status."

"For the 2014 reporting period, 47 states reported that a total of 5,780,207 individuals received mental health services; for the 2015 reporting period, 45 states reported that a total of 5,261,722 individuals received mental health services; for the 2016 reporting period, 47 states reported that a total of 5,748,830 individuals received mental health services; for the 2017 reporting period, 48 states reported that a total of 5,852,482 individuals received mental health services; for the 2018 reporting period, 48 states reported that a total of 6,075,486 individuals received mental health services; and for the 2019 reporting period, 47 states reported that a total of 6,362,044 individuals received mental health services.⁶

"Gender
"Tables 1.2a–b. Females accounted for between 51 and 52 percent of all individuals served in every reporting period between 2014 and 2019.

"Age group
"Tables 1.2a–b. In all six reporting periods from 2014 through 2019, between 28 and 29 percent of individuals served were aged 17 years and younger; 10 percent were aged 18 to 24 years; between 44 and 46 percent were aged 25 to 54 years; and between 15 and 17 percent were aged 55 years and older. The most frequently reported diagnoses among specific age groups across the six reporting periods are reported in Tables 1.4a–1.7b and are further discussed in Chapters 2 through 5.

"Antidepressants are medications commonly used to treat depression. Antidepressants are also used for other health conditions, such as anxiety, pain and insomnia. Although antidepressants are not FDA-approved specifically to treat ADHD, antidepressants are sometimes used to treat ADHD in adults.

"The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). Examples of SSRIs include:

"Fluoxetine
"Citalopram
"Sertraline
"Paroxetine
"Escitalopram
"Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine and duloxetine.

"Another antidepressant that is commonly used is bupropion. Bupropion is a third type of antidepressant which works differently than either SSRIs or SNRIs. Bupropion is also used to treat seasonal affective disorder and to help people stop smoking.

"SSRIs, SNRIs, and bupropion are popular because they do not cause as many side effects as older classes of antidepressants, and seem to help a broader group of depressive and anxiety disorders. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or MAOIs may be the best medications."

"The most common side effects listed by the FDA include:

"Nausea and vomiting
"Weight gain
"Diarrhea
"Sleepiness
"Sexual problems

"Call your doctor right away if you have any of the following symptoms, especially if they are new, worsening, or worry you(U.S. Food and Drug Administration, 2011):

"Thoughts about suicide or dying
"Attempts to commit suicide
"New or worsening depression
"New or worsening anxiety
"Feeling very agitated or restless
"Panic attacks
"Trouble sleeping (insomnia)
"New or worsening irritability
"Acting aggressively, being angry, or violent
"Acting on dangerous impulses
"An extreme increase in activity and talking (mania)
"Other unusual changes in behavior or mood

"Combining the newer SSRI or SNRI antidepressants with one of the commonly-used "triptan" medications used to treat migraine headaches could cause a life-threatening illness called "serotonin syndrome." A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications. For more information, please see the FDA Medication Guide on Antidepressant Medicines

"Antidepressants may cause other side effects that were not included in this list. To report any serious adverse effects associated with the use of antidepressant medicines, please contact the FDA MedWatch program using the contact information at the bottom of this page. For more information about the risks and side effects for each medication, please see Drugs@FDA."

"Anti-anxiety medications help reduce the symptoms of anxiety, such as panic attacks, or extreme fear and worry. The most common anti-anxiety medications are called benzodiazepines. Benzodiazepines can treat generalized anxiety disorder. In the case of panic disorder or social phobia (social anxiety disorder), benzodiazepines are usually second-line treatments, behind SSRIs or other antidepressants.

"Benzodiazepines used to treat anxiety disorders include:
"Clonazepam
"Alprazolam
"Lorazepam

"Short half-life (or short-acting) benzodiazepines (such as Lorazepam) and beta-blockers are used to treat the short-term symptoms of anxiety. Beta-blockers help manage physical symptoms of anxiety, such as trembling, rapid heartbeat, and sweating that people with phobias (an overwhelming and unreasonable fear of an object or situation, such as public speaking) experience in difficult situations. Taking these medications for a short period of time can help the person keep physical symptoms under control and can be used “as needed” to reduce acute anxiety.

"Buspirone (which is unrelated to the benzodiazepines) is sometimes used for the long-term treatment of chronic anxiety. In contrast to the benzodiazepines, buspirone must be taken every day for a few weeks to reach its full effect. It is not useful on an “as-needed” basis."

"Like other medications, anti-anxiety medications may cause side effects. Some of these side effects and risks are serious. The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:
"Nausea
"Blurred vision
"Headache
"Confusion
"Tiredness
"Nightmares

"Tell your doctor if any of these symptoms are severe or do not go away:
"Drowsiness
"Dizziness
"Unsteadiness
"Problems with coordination
"Difficulty thinking or remembering
"Increased saliva
"Muscle or joint pain
"Frequent urination
"Blurred vision
"Changes in sex drive or ability (The American Society of Health-System Pharmacists, Inc, 2010)

"If you experience any of the symptoms below, call your doctor immediately:
"Rash
"Hives
"Swelling of the eyes, face, lips, tongue, or throat
"Difficulty breathing or swallowing
"Hoarseness
"Seizures
"Yellowing of the skin or eyes
"Depression
"Difficulty speaking
"Yellowing of the skin or eyes
"Thoughts of suicide or harming yourself
"Difficulty breathing

"Common side effects of beta-blockers include:
"Fatigue
"Cold hands
"Dizziness or light-headedness
"Weakness
"Beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms related to both.

"Possible side effects from buspirone include:
"Dizziness
"Headaches
"Nausea
"Nervousness
"Lightheadedness
"Excitement
"Trouble sleeping

"Anti-anxiety medications may cause other side effects that are not included in the lists above. To report any serious adverse effects associated with the use of these medicines, please contact the FDA MedWatch program using the contact information at the bottom of this page. For more information about the risks and side effects for each medication, please see Drugs@FDA."

"For the 2015 reporting period, states reported a total of 720,987 individuals served aged 12 and older (14 percent of all individuals served) had co-occurring mental health and substance use disorders.

"During this period, the data show that mental health diagnoses differed somewhat across categories for several variables, including gender, age group, race, ethnicity, living arrangements, employment and detailed “not in labor force,” service setting, and timing of admission. Mental health diagnoses were largely similar across SMI/SED status and level of functioning.

"Gender
"• Tables 6.1a-c. During the 2015 reporting period, for males served who had co-occurring mental health and substance use disorders, the most frequently reported diagnoses were schizophrenia and other psychotic disorders and depressive disorders (25 percent each).

"• For their female counterparts, the most frequently reported diagnoses were depressive disorders (33 percent) and bipolar disorders (29 percent).

"Age
"• Tables 6.1a-c. The most frequently reported diagnoses for individuals served aged 30 to 44 who had co-occurring mental health and substance use disorders were bipolar disorders (from 28 percent to 29 percent).

"• The most frequently reported diagnoses for individuals served aged 45 and older with co-occurring substance use and mental health disorders were depressive disorders (from 31 percent of those aged 45 to 49 to 35 percent of those aged 55 to 64)."

"In the 2015 reporting period, mental health diagnoses among individuals served who had co-occurring mental health and substance use disorders differed very little by substance use diagnosis. (Unlike mental health diagnoses, where up to three diagnoses are recorded per client record, each client record contains only one substance use diagnosis. See the final section of Appendix E for definitions of substance abuse codes.)

"• Bipolar disorders were the most frequently reported mental health diagnoses for individuals served who had co-occurring marijuana dependence (29 percent).

"• Depressive disorders were the most frequently reported diagnoses for individuals served who had co-occurring alcohol dependence (36 percent), opioid dependence and non-dependent opioid use (35 percent each), or cocaine dependence (30 percent).

"• Bipolar disorders were the most frequently reported mental health diagnoses for individuals served who had co-occurring non-dependent cocaine use (29 percent), non-dependent marijuana use (26 percent), or other non-dependent substance use (26 percent).

"• Depressive disorders and bipolar disorders were the most frequently reported diagnoses for individuals served who had co-occurring non-dependent alcohol use (31 and 25 percent, respectively)."

"Of the 105,860 clients who received inpatient mental health treatment services on April 29, 2016, 32 percent were in general hospitals, 29 percent were in public psychiatric hospitals, and 28 percent were in private psychiatric hospitals."

"Gender"
"Despite some variation across facility type, 58 percent of clients who received inpatient mental health treatment services were male. Veterans Administration medical centers and public psychiatric hospitals accounted for the highest percentages of males who received inpatient services (83 and 69 percent, respectively).

"Age"
"• Sixteen percent of clients who received inpatient mental health treatment services were aged 17 or younger, while 68 percent were aged 18 to 64, and 16 percent were aged 65 and older.
"• Ninety-eight percent of clients who received inpatient services in RTCs for children were aged 17 or younger, and 2 percent were aged 18 to 64. (RTCs for children varied in how they defined children; some facilities included youth up to age 21. Reports of clients aged 65 and older who received inpatient mental health treatment services in RTCs for children likely constitute reporting errors.)
"• Private psychiatric hospitals served a greater proportion of children aged 17 and younger (25 percent) than general hospitals or public psychiatric hospitals (9 and 5 percent, respectively).
"• Eighty-five percent of clients served in public psychiatric hospitals were aged 18 to 64.
"• General hospitals and VA medical centers reported the largest proportions (24 percent each) of clients aged 65 and older who received inpatient mental health treatment services.

"Race"
"Race information was missing or reported as unknown for 51 percent of clients who received inpatient mental health treatment services on April 29, 2016. Of the clients for whom race information was reported, 31 percent of all those who received inpatient mental health treatment services were white;; 15 percent were Black or African American, and 1 percent each were Asian or two or more races.
"All types of facilities that provided inpatient mental health treatment services served a greater proportion of White clients than clients of any other racial group.
Of clients who received inpatient services in residential treatment centers (RTCs) for children, , 29 percent were Black or African American [Figure 3.2].

"Ethnicity"
"Ethnicity information was missing or reported as unknown for 49 percent of clients who received inpatient mental health treatment services. Forty-five percent were not Hispanic or Latino and 6 percent were Hispanic or Latino."

"Across all facility types, half of all clients who received inpatient mental health treatment services on April 29, 2016, were involuntarily admitted for care: 38 percent of clients were admitted with an involuntary non-forensic (non-criminal) legal status and 15 percent were admitted with an involuntary forensic (criminal) legal status.
Involuntary admissions were highest (91 percent) for clients who received inpatient mental health treatment services in RTCs for children and lowest (19 percent) for clients who received inpatient mental health treatment services in another type of residential treatment facility."

"Of the 65,324 clients who received residential mental health treatment services on April 29, 2016, 35 percent received services in RTCs for children and 27 percent received services in RTCs for adults.

"Gender"
"A greater proportion of clients who received residential mental health treatment services on April 29, 2016, were male (61 percent) than female. This finding is consistent with the gender composition of clients who received inpatient mental health treatment services.
"VA medical centers and public psychiatric hospitals had the highest proportions of males who received residential mental health treatment services (87 and 69 percent, respectively).

"Age"
"As shown in Table 3.2a-b, clients between 18 and 64 years old accounted for 49 percent of all clients who received residential mental health treatment services on April 29, 2016, while 45 percent were age 17 or younger, and 5 percent were 65 years or older.

"Race"
"Race information was missing or reported as unknown for 40 percent of clients who received residential mental health treatment services on April 29, 2016. White clients accounted for 37 percent of all those who received residential mental health treatment services, while 17 percent were Black or African American, 3 percent were two or more races, and clients who identified as Asian or as American Indian/Alaska Native comprised 1 percent each.
"As shown in Figure 3.4, all types of facilities provided residential mental health treatment services to higher percentages of White clients than Black or African American clients, except for partial hospitalization/day treatment facilities.

"Ethnicity"
Ethnicity information was missing or reported as unknown for 36 percent of clients who received residential mental health treatment services. Clients who identified as Hispanic or Latino accounted for 8 percent of clients, while 56 percent did not identify as Hispanic or Latino."

"Overall, 71 percent of all clients who received residential mental health treatment services on April 29, 2016, were voluntarily admitted for care, and the remaining 29 percent were admitted with an involuntary legal status."

"Of the 4,161,697 clients who received outpatient mental health treatment services at least once in April 2016 and were still enrolled in treatment on April 29, 2016, 46 percent received services in outpatient mental health facilities and 32 percent received services in community mental health centers. VA medical centers accounted for 9 percent of clients served in less than 24-hour outpatient settings, while multi-setting mental health facilities and general hospitals accounted for 4 percent each.

"Gender"
"Unlike the gender distribution of clients who received inpatient and residential mental health treatment services, the proportion of males and females receiving outpatient mental health treatment services was similar: 51 percent were male and 49 percent were female. A notable exception was VA medical centers, which predominantly served males (77 percent).

"Age"
"Children aged 17 or younger accounted for 27 percent of clients who received outpatient mental health treatment services; 60 percent of clients were adults aged 18 to 64, and 13 percent were seniors aged 65 and older.
"As shown in Figure 3.5, RTCs for children served children in higher proportions than all other facility types. Adults aged 18 to 64 received outpatient services in higher proportion than other age groups in other types of residential treatment facilities (76 percent), VA medical centers (68 percent), and public psychiatric hospitals (67 percent). Clients aged 65 and older accounted for about a quarter of those who received outpatient services in both private psychiatric hospitals and VA medical centers (28 and 23 percent, respectively).

"Race"
"Race information was missing or reported as unknown for 46 percent of clients who received outpatient mental health treatment services. According to the reported race information, 35 percent of clients who received outpatient services were White, 12 percent were Black or African American, 5 percent were two or more races, and 1 percent each were Asian or American Indian/Alaska Native.
"Figure 3.6 compares the proportions of White and Black or African American clients receiving outpatient mental health treatment services by facility type. As with residential settings, all facilities served a greater proportion of White than Black or African American clients.

"Ethnicity"
"Ethnicity information was missing or reported as unknown for 41 percent of clients who received outpatient services. Clients who identified as Hispanic or Latino accounted for 11 percent of those served as outpatients, while 48 percent did not identify as Hispanic or Latino."

"Overall, 92 percent of clients who received outpatient services received care voluntarily, while the other 8 percent received care involuntarily."

"Overall, the prevalence of 6.3% for lifetime DSM-5 PTSD in U.S. veterans is lower than that reported in previous studies of era-specific (18.7% and 52%) (Dohrenwend et al., 2007; Ikin et al., 2010; Jakupcak et al., 2010) veteran cohorts but similar to a national sample of veterans (7.95%; Wisco et al., 2014) using previous diagnostic classifications. In part this may reflect the narrow definition used in the study. However, the lifetime prevalence of PTSD among veterans in this study was very similar to the prevalences of 6.4% and 7.8% reported for DSM-IV PTSD in the general U.S. populations (Kessler et al., 1995; Pietrzak et al., 2011b). Similar to prior studies of veteran and general population samples, prevalence of PTSD was higher among women, and those with PTSD were more likely to be younger, non-white, and have lower income, in addition to reporting more traumatic events (Wisco, et al., 2014; Pietrzak et al., 2011b; Kessler et al., 1995).

"With adjustment for sociodemographic characteristics, PTSD was highly comorbid with all lifetime substance use and aggregate psychiatric disorders assessed in the NESARC-III. These estimates were lower for mood, alcohol use and drug use disorder, higher for nicotine use disorder and similar for anxiety disorders compared to the other recent nationally representative estimates among U.S. veterans (Wisco et al., 2014). Despite changes in diagnostic criteria for PTSD and many other disorders from DSM-IV to DSM-5, they were consistent with previous studies of the general U.S. population (Pietrzak et al., 2011b; Kessler et al., 1995). In models adjusting for only sociodemographic characteristics, PTSD was associated with substance use disorders (AOR=2.1–3.4) and especially mood, anxiety, and personality disorders (AOR=9.6–11.1). After further adjustment for other psychiatric disorders, associations between PTSD and substance use disorders were no longer significant, whereas associations between PTSD and mood, anxiety, and PDs were attenuated. These weaker associations, when adjusting models for psychiatric disorders, suggests shared factors underlying these associations. That the associations between PTSD and mood, anxiety, and PD remained significant, points to possible unique factors contributing to these associations (Agrawal and Lynskey, 2008; Awofala, 2013; Ball, 2008)."

"In this study, the highest levels of comorbidity (six or more comorbid conditions) among veterans were observed among treatment seekers. However, only those with comorbid DUD [Drug Use Disorders] were significantly more likely to seek treatment for PTSD once potentially confounding factors were accounted for. It is of concern that, in the present sample, 32% of veterans with PTSD who did not seek treatment had 6+ comorbid conditions. The 14.8% increase in completion of at least one PTSD treatment visit between 2005 and 2010, compared with 12.6% from 1997–2005 among veterans seen in the VA healthcare system (Hermes et al., 2012), is encouraging. Similarly, Mott et al., (Mott et al., 2014) recently reported an increase in psychotherapy utilization among veterans across three time points (FY 2004, 21%; FY 2007, 22%; and FY 2010, 27%). Although most of these increases were seen in those with anxiety and depression, those with PTSD had the highest rate of initiation and number of psychotherapy sessions. Nevertheless, the persistently low rates of help seeking, despite the availability of empirically supported psychotherapies and pharmacotherapies that can prevent psychiatric disorders, including PTSD, from becoming chronic (Bryant et al., 2003; Katon et al. 1996; Simon et al., 2004) is cause for concern. Although treatment may be available, it may not be accessible to all veterans who need it due to lack of proximity to these services (Lazar, 2014). Taken together these results call for efforts to understand low rates of help seeking and use the knowledge gained to increase uptake by veterans with PTSD who could benefit from these interventions wherever they present."

"Drug use disorder was highly associated with alcohol and nicotine use disorders, with ORs (95% CIs) ranging from 2.5 (2.00–3.06) to 4.4 (3.80–5.19) across time frames and severity levels (Table 3). Twelve-month DUD was also positively associated with major depressive disorder, bipolar I, posttraumatic stress disorder, and antisocial PD (any and moderate to severe); dysthymia (any and mild); and borderline and schizotypal PDs across severity levels. Lifetime DUD was associated with major depressive disorder and generalized anxiety disorder (any and mild); bipolar I, dysthymia, posttraumatic stress disorder, and borderline and schizotypal PDs (except mild); and panic disorder, social phobia, and antisocial PD across severity levels."

"In 2012 through 2013, US prevalences of DSM-5 12-month and lifetime AUD [Alcohol Use Disorder] among adults 18 years and older were 13.9% and 29.1%, respectively, representing approximately 32 648 000 and 68 485 000 individuals, respectively, in the United States. Corresponding DSM-IV rates, 12.7% and 43.6%, respectively, increased substantially since 2001 through 2002 (8.5% and 30.3%, respectively).6 Increases in DSM-IV AUD during the past decade may partly reflect increases in heavy alcohol consumption during that period: past-year drinking of at least 5, at least 8, and at least 10 drinks/d increased from 31.0%, 15.6%, and 11.5%, respectively, in the 2001-2002 NESARC to 39.6%, 20.8%, and 15.5%, respectively, in the 2012-2013 NESARC-III (R.B.G., unpublished data, February 2015). In contrast, rates of 12-month AUD remained stable from 2002 and 2013 (about 7.5%) in the National Survey on Drug Use and Health.15 More research on reasons for increasing prevalence of AUD during the past decade and discrepancies in the rates between national surveys is warranted."

"Consistent with previous research, rates of AUD [Alcohol Use Disorder] were greater among men than women.1,2,5,14 Age was inversely related to 12-month AUD, a finding also observed in earlier epidemiologic studies.1-5,14 Whether this result is owing to cohort effects, differential mortality, or recall bias merits further investigation. The 12-month rate of 7.1% for severe AUD among 18- to 29-year-old respondents is especially striking. The rate is consistent with the earlier age at onset of severe relative to mild or moderate AUD (23.9 vs 25.9 or 30.1 years, respectively) and increasing rates of heavy drinking in this age group. For example, among men, past-year drinking of at least 5, at least 8, and at least 10 drinks/d increased from 60.7%, 41.0%, and 33.9%, respectively, in the NESARC [National Epidemiologic Survey on Alcohol and Related Conditions III] to 68.2%, 46.3%, and 38.0%, respectively, in the NESARC-III. In women, the increase was from 33.5%, 14.7%, and 8.7%, respectively, in the NESARC to 47.7%, 22.1%, and 14.2%, respectively, in the NESARC-III (R.B.G, unpublished data, February 2015). Thus, emerging adulthood is becoming an increasingly vulnerable period for AUD onset. Given the potential effect of young-adult AUD on long-term employment prospects in a changing economy and the risk for young-adult alcohol-related mortality, the increases suggest an urgent need to develop and implement more effective prevention and intervention efforts.

"Study findings indicate a lower risk for AUD among black, Asian or Pacific Islander, and Hispanic than white respondents. Although genetic factors affecting alcohol metabolism likely influence lower rates among Asian respondents,42,43 understanding risk factors among white respondents and protective factors among black and Hispanic respondents will be important to elucidate the etiology of AUD and design better prevention and intervention programs. In contrast, Native American respondents had high rates of 12-month and lifetime severe AUD. These results are consistent with regional studies of Native Americans showing high rates of alcohol-related morbidity and mortality44-46 and underscore the need for more extensive prevention and intervention efforts in this group."

"We generally found significant associations between 12-month and lifetime AUD and other substance use disorders, major depressive disorder, bipolar I disorder, specific phobia, and antisocial and borderline PDs when we controlled for sociodemographic characteristics and other disorders. Significant associations between persistent depressive disorder, posttraumatic stress disorder, panic disorder, and generalized anxiety disorder with lifetime AUD were also observed. That these associations were weaker than those when we only controlled for sociodemographic variables suggests common causal factors underlying the pairwise comorbid associations. Moreover, that these associations remained significant after additional control for comorbid disorders indicates the possibility of unique underlying factors contributing to the disorder-specific associations.47-49 These findings, consistent with genetic studies, highlight the need for further investigation of the unique and common factors underlying AUD comorbidity. Within this framework, special emphasis should be given to sociodemographic risk factors identified herein (education and income) that may interact with genetic vulnerability to influence phenotypic expression of AUD.

"Despite increased AUD prevalence during the past decade, this study showed that AUD largely goes untreated. Rather than lack of insurance, fears of stigmatization and beliefs that treatment is ineffective explain the lack of AUD treatment in the United States.50-54 Nonetheless, a large body of literature supports the effectiveness of treatment of AUD. Prior NESARC findings55 show that participation in 12-step groups increases the likelihood of recovery, consistent with randomized clinical trials testing the efficacy of 12-step facilitation administered by health care practitioners.56 Reviews and meta-analyses of randomized trials involving thousands of patients have demonstrated the efficacy of brief screening and intervention in primary care settings among individuals whose alcohol problems are not yet severe.57-60 For more severe problems, effective medications include oral and extended-release naltrexone hydrochloride, acamprosate calcium, and disulfiram61-65; evidence-based behavioral treatments include 12-step facilitation,56 motivational interviewing,66-68 and cognitive-behavioral therapy.68-70 Effective treatment might be more widely accessed if public and professional education programs targeted mistaken attitudes about treatment efficacy and provided information about where to obtain treatment.

"All measures of current disability were strongly related to 12-month AUD, increasing with AUD severity. These findings highlight the seriousness of AUD, particularly among never-treated individuals. Prior research has shown significantly less disability among those treated for an AUD than those never treated.71,72 When untreated, AUD-related functional impairment also has been associated with diminished life chances, increased stressful life conditions, and increased risk for and severity of other psychiatric disorders, even after AUD remission.73 These findings suggest that AUD treatment should aim to remediate impaired functioning in addition to targeting alcohol consumption."

"Past-year (4.7%) and lifetime (6.1%) prevalences of DSM-5 PTSD represent 10,972,986 and 14,411,005 affected U.S. adults, respectively. Broadly consistent with previous findings [3, 4, 42, 43], prevalences were higher among women and respondents aged <65 years, previously married, and with <high school education and household income <$70,000. Rates were also higher among Native American, but lower among Asian and Pacific Islander and Hispanic, versus non-Hispanic white, respondents, and lower among urban than rural residents. Past-year PTSD was less likely among Midwestern than Western residents. Taken together, these results indicate the need to characterize risk and protective factors, and underlying mechanisms, related to sociodemographic characteristics to improve understanding of the etiologies of both exposure to PTEs and PTSD and tailor prevention and intervention appropriately to subgroups at risk [3, 43].

"In the total NESARC-III sample, lifetime prevalence of PTE exposure (68.6%) was higher than reported by Kessler et al. [42] based on DSM-III-R criteria, but lower than those in recent studies [3, 22, 44, 45] based on DSM-IV, including Wave 2 of the NESARC. These differences likely reflect the broader range of qualifying events in DSM-IV than DSM-III-R or DSM-5. Nevertheless, rank-orderings of the most common exposures, particularly among respondents with PTSD, and differences by sex, were generally similar to those reported previously [4, 42–44]."

"Conflicts and wars are known to contribute to a higher burden of mental health problems among specific individuals who experience trauma as well as among those living in or near to conflict zones, even across generations [3–5]. Post-traumatic stress disorder is mostly recognized as the mental health burden; however, during conflict there is also significant disability from common mental health problems such as depression, anxiety, and substance misuse. From the Somalian conflict, these have been linked with the poverty associated with economic fragmentation and with a reduction of basic security functions and safety [6]. The link between armed conflict and the production and trafficking of illicit drugs has been noted in the literature, and recent research indicates a link between lootable resources, including opioids, and conflict duration [7]."

"As noted in a systematic review by Horyniak and colleagues (2016), forced migrants have commonly witnessed and personally experienced pre- and post-migration stress and trauma, including loss of homes and livelihoods, violence, and family separation [8]. Among this population, the prevalence of mental health disorders, specifically depression and post-traumatic stress disorder, are particularly high due to this lived experience [9–11]. In past studies, comorbidity between mental health and substance use disorders has been well documented in the general population [12–14]. An emerging literature has begun on substance use as coping mechanism to document comorbidity among forced migrant populations [15–17].

"Also, forced migrants experience acculturation challenges, the process of cultural and psychological change that follows contact with a culture other than one’s own [18]. It has been hypothesized that migrants who are highly engaged in the host culture (‘assimilation’) may engage in substance use and addiction in order to adhere to mainstream norms and gain acceptance in their new communities [18–20]. Acculturation is an especially important factor for younger migrants, whose experiences are compounded by intergenerational conflict, and peer pressure as found in previous studies among Sudanese and Latino adolescents [19–23]. For example, in a study among ninth-grade adolescents, low levels of interest in maintaining their native culture alongside low levels of participation in their new culture, often due to discrimination and exclusion, has been associated with substance use [24] Additionally, forced migrants, commonly experience social and economic inequality, marginalization and discrimination [25–28]. These factors have been shown to be important determinants of health, and could contribute to feelings of stress and powerlessness, which may contribute to substance use [29–31]. In addition, forced migrants could be exposed to illicit drugs as well through their residence in disadvantaged neighborhoods where drugs may be readily available leading to increased morbidity and mortality [32,33]. As a contributing factor, the HIV outbreak in Ukraine has spread throughout the nation. According to Public Health Center of the Ministry of Health of Ukraine, Ukraine continues to have high rates of HIV infection in Eastern Europe and Central and Eastern Asia [34]."

"The present study is the first to compare the clinical profiles of SUD+PTSD [Substance Use Disorder + Post Traumatic Stress Disorder] individuals with a history of CT [Childhood Trauma] to those with a history of adulthood only trauma. In line with previous research in the substance use literature, participants reported alarmingly high rates of CT exposure (77%) and childhood sexual abuse (55%) (Karadag et al., 2005; Medrano et al., 1999; Plotzker et al., 2007; Wu et al., 2010). Nonetheless, it is possible that these are actually underestimates of the true prevalence as these data are based on retrospective recall. Studies that have compared retrospective self-report against court records of abuse have shown that people often underreport histories of childhood sexual and physical abuse (Widom & Morris, 1997); (Widom & Shepard, 1996).

"The median age of onset of trauma exposure was 8 years, highlighting the importance of screening for trauma exposure in children by health care providers. Early detection is necessary so that early interventions may be implemented that may prevent that development of subsequent trauma-related mental health problems.

"The mental health of participants in the present study was poor. Consistent with previous studies of SUD+PTSD samples, there were high rates of depression (Brady, Killeen, Saladen, Dansky, & Becker, 1994; Tarrier & Sommerfield, 2003), anxiety (Najavits et al., 1998; Tarrier & Sommerfield, 2003) and BPD (Van Den Bosch, Verheul, Langeland, & Van Den Brink, 2003). Important differences were observed in relation to trauma, PTSD and substance use. The CT+ group experienced more trauma types in their lifetime compared to the CT− group. This finding is in accordance with a large body of literature that has found associations between CT, particularly CSA, and risk of re-traumatisation in adulthood (Arata, 2002; Desai, Arias, Thompson, & Basile, 2002; Jankowski, Leitenberg, Henning, & Coffey, 2002; Messman & Long, 1996). This is of clinical importance, as re-traumatisation has been associated with more complex PTSD symptom presentation (Briere, Kaltman, & Green, 2008; Cloitre et al., 2009; Gibson & Leitenberg, 2001), and other co-occurring anxiety disorders, such as generalised anxiety disorder, simple phobia and social phobia, as well as higher rates of suicide attempts and depression (Cloitre, Scarvalone, & Difede, 1997).

"As expected, the CT+ group had also experienced PTSD symptoms for a longer period of time, highlighting the chronic and pervasive nature of PTSD associated with CT. Despite having suffered PTSD for an average of 10 years very few had accessed treatment, highlighting an area of unmet need.

"Individuals with a history of CT presented with a more severe clinical profile in relation to a number of substance use characteristics when compared to those who experienced trauma confined to adulthood. The CT+ group had an earlier age of onset of substance use, had more extensive polydrug use histories, and a greater severity of dependence. These findings emphasise the long term effects and clinical implications associated with early trauma experiences and substance use. Given these findings it is not surprising that participants in the CT+ group also had higher rates of previous drug treatment episodes, which may indicate that current treatment programs are not addressing the needs of those who have a history of CT (Mills et al., 2005). The additional service utilisation among CT+ individuals translates into higher costs for the health care system, emphasising the need for appropriate treatment to be provisioned to this group (Hidalgo & Davidson, 2000)."

"Assessing both CUD [Cannabis Use Disorder] and cannabis use status and their associations with suicidal ideation, plan, and attempt, we found that suicidality trends varied by sex, depression, and both CUD and cannabis use status. Our results suggest that CUD, daily cannabis use, and even nondaily cannabis use were associated with a higher prevalence of suicidal ideation, plan, and attempt more significantly in women than in men. Specifically, the adjusted prevalence of past-year suicidal ideation was higher among women with CUD regardless of MDE [Major Depressive Episode] status and among women without MDE but with daily or nondaily cannabis use compared with their male counterparts. We found upward trends in suicidal ideation among women (rather than men) with MDE and CUD or daily and nondaily cannabis use. Compared with their male counterparts, the adjusted prevalence of suicide plan and attempt were higher among women with MDE and CUD or daily cannabis use and among women without MDE but with CUD or daily and nondaily cannabis use. Similarly, from 2008 to 2019, we found an upward trend in suicide plan among women (rather than men) with MDE and daily cannabis use and an upward trend in suicide attempt among women (rather than men) with MDE and CUD. By contrast, among individuals with neither MDE nor cannabis use, the adjusted prevalence of suicidal ideation, plan, and attempt were similar between men and women, and the adjusted prevalence of suicidal ideation was lower among women with MDE without CUD or cannabis use compared with their male counterparts."

"Our results, along with those from a recent study,⁴⁸ suggest that adults with MDE [Major Depressive Episode] may be particularly vulnerable to cannabis use as beliefs in its therapeutic potential become more widespread and products become more accessible. Moreover, even after adjusting for depression, CUD, cannabis use status, and other potential confounding factors, we found that from 2008 to 2019 among adults aged 18 to 34 years, the adjusted prevalence of suicidal ideation increased 1.4-fold; suicide plan, 1.6-fold; and suicide attempt, 1.4-fold. Furthermore, even for those with neither MDE nor cannabis use, we found upward trends in suicidal ideation and plan among both men and women and in suicide attempt among men. Our results indicate that depression and cannabis use are associated with suicidality but do not appear to be the only causes for the upward trends in suicide among young adults."

"In the 2015 reporting period, six states and jurisdictions (Connecticut [adults only], the District of Columbia, Louisiana, Mississippi, Oklahoma, and Puerto Rico) reported a total of 417,443 admissions to MH-TEDS [Mental Health Treatment Episode Data Set]. [Table 7.1]:

"• Of admissions who began treatment prior to the 2015 reporting period, 69 percent of admissions received treatment in community programs, 57 percent in residential treatment centers, 43 percent in state psychiatric hospitals, and 31 percent in institutions under the justice system [Table 7.1].

"• More than half (66 percent) of admissions for individuals in treatment during the 2015 reporting period occurred prior to the reporting period [Table 7.2b].

"• There were more male than female admissions for ADD/ADHD, conduct disorder, and oppositional defiant disorder. There were more female than male admissions for adjustment disorders, anxiety disorders, bipolar disorders, and depressive disorders [Table 7.3a,Table 7.10a].

"Client Outcomes Among Individuals Receiving Mental Health Services: 2012 and 2015
"States reported a total of 701,355 individuals served in 2012 that were also reported to have received services in the 2015 reporting period and had known living arrangements in 2012 [Table 8.1a].

"• Among individuals served in both the 2012 and 2015 reporting periods overall, less than one-third of those who were homeless in 2012 also reported being homeless in 2015 (29 percent) [Figure 2].

"States reported a total of 497,340 individuals served in 2012 that were also reported to have received services in the 2015 reporting period and had known employment status in 2012 [Table 8.3a].

"• A higher percentage of individuals served in both periods reported being unemployed among those with alcohol and drug related disorders (69 percent) compared with all individuals served in both periods that reported being unemployed in 2012 and 2015 (51 percent) [Figure 5]."

"In this nationwide study of commercially insured adolescents, LTOT [Long Term Opioid Therapy] was relatively uncommon. The estimated incidence of LTOT receipt was 3.0 per 1000 adolescents within 3 years of filling an initial opioid prescription. Although adolescents with a wide range of preexisting mental health conditions and treatments were modestly more likely than adolescents without those conditions or treatments to receive an initial opioid, the former had substantially higher rates of subsequent transitioning to LTOT. Associations were strongest for OUD [Opioid Use Disorder], OUD medications, nonbenzodiazepine hypnotics, and other SUDs. The associations were stronger sooner after first opioid receipt for OUD, as well as for anxiety and sleep disorders and their treatments, suggesting that adolescents with these conditions and treatments were more likely to quickly transition into LTOT."

"Alcohol is, by far, the most widely used drug among college students, with 60.8% of students reporting alcohol use in the past month (Substance Abuse & Mental Health Services Administration, 2012). In 2009, 61.5% of college students reported that they had been intoxicated at least once in the past year, with 42.4% reporting that they had been intoxicated in the past 30 days (Johnston, O'Malley, Bachman, & Schulenberg, 2010). Approximately 37 to 44% of college students reported that they binge drank at least once in the past two weeks to month (Hingson, Heeren, Winter, & Wechsler, 2005; Johnston et al., 2010; Wechsler et al., 2002).

"Alcohol use can lead to a wide range of problems (e.g., involvement in risky sexual situations, driving under the influence, hangovers, nausea and vomiting, and aggression). Due to the high levels of alcohol consumption and the contexts in which college students typically consume alcohol (e.g., parties where excessive drinking is the norm), along with no parental oversight and monitoring, this population may be particularly likely to experience alcohol-related problems (ARPs). Of college students who drank at least once per week during their first year of college, 80% experienced more than one ARP during their first year, and 34% reported that they had experienced six or more ARPs during that time (Mallett et al., 2011)."

"Of the 1,000,453 opioid recipients (81.7%) with at least 6 months of follow-up, 51.1% were female, and the median age was 17 years (interquartile range, 16-18 years). Among these adolescents, the estimated cumulative incidence of LTOT [Long Term Opioid Therapy] after first opioid receipt was 1.1 (95% CI, 1.1-1.2) per 1000 recipients within 1 year, 3.0 (95% CI, 2.8-3.1) per 1000 recipients within 3 years, 8.2 (95% CI, 7.8-8.6) per 1000 recipients within 6 years, and 16.1 (95% CI, 14.2-18.0) per 1000 recipients within 10 years. The prevalence of mental health conditions and treatments in this sample is shown in eTable 3 in the Supplement.

"All mental health conditions and treatments were associated with higher rates of transitioning from a first opioid prescription to long-term therapy. Table 2 provides the estimated incidence of LTOT among those with and without mental health conditions and treatments.Adjusted relative increases in the rate of LTOT ranged from a factor of 1.73 for ADHD [Attention-Deficit/Hyperactivity Disorder] (hazard ratio [HR], 1.73; 95% CI, 1.54-1.95) to approximately 4-fold for benzodiazepines (HR, 3.88; 95%CI, 3.39-4.45) and nonopioid SUDs [Substance Use Disorders] (HR, 4.02;95%CI, 3.48-4.65) to 6-fold for non benzodiazepine hypnotics (HR, 6.15; 95%CI, 5.01-7.55) and to nearly 9-fold for OUD [Opioid Use Disorder] (HR, 8.90; 95%CI, 5.85-13.54). In addition, relative to no condition, the number of condition types was also associated with higher LTOT rates (1 condition: HR, 2.21; 95% CI, 2.01-2.43; 2 or more conditions: HR, 4.01; 95% CI, 3.62-4.46).

"Given the strong associations for OUD, we explored other mental health factors and opioid receipt among those with preexisting OUD. These adolescents were more likely than
adolescents without OUD to have other mental health conditions and treatments (eTable 4 in the Supplement). For example, 76.1% of adolescents with OUD had other SUDs, 61.0% had depressive disorders, and 52.6% had received an SSRI [Selective Serotonin Reuptake Inhibitor]. During follow-up, those with preexisting OUD received opioid drugs similar to those received by adolescents without OUD, although the former were more likely to receive certain opioids (eg, oxycodone and tramadol; eTable 5 in the Supplement). Of those with preexisting OUD, 15.5% filled a prescription for OUD medication treatment during follow-up."

"CUD [Cannabis Use Disorder] is defined in the DSM-5 as a problematic pattern of cannabis use leading to clinically significant impairment or distress occurring within a 12-month period as manifested by cannabinoid tolerance and withdrawal; increasing amounts of cannabis use over time; inability to control consumption; craving; and recurrent cannabis use having negative implications on social, professional and educational life [3]. Withdrawal symptoms usually appear approximately 24 hours after abstinence initiation, peak within two to six days and remit within two weeks [4]. Symptoms may include irritability, anger or aggression; nervousness or anxiety; sleep difficulty (insomnia, disturbing dreams); decreased appetite or weight loss; restlessness; depressed mood; or physical discomforts (abdominal pain, shakiness/tremors, fever, chills or headache) [5, 6, 7•]. Withdrawal is diagnosed if at least three of these symptoms develop. A week after cessation of use, additional symptoms may appear such as fatigue, yawning, difficulty in concentration, and rebound periods of increased appetite or hypersomnia [3]."

"Social anxiety disorder (SAD) and alcohol use disorders (AUDs) are frequently comorbid (see Morris, Stewart, and Ham (2005), for a review). Approximately 13% of adults with past-year SAD met criteria for a comorbid AUD, and of adults with lifetime SAD, 48.2% met criteria for an AUD (Grant et al., 2005). This relationship appears to be due to a greater likelihood of having comorbid alcohol dependence (characterized by tolerance, withdrawal, or compulsive alcohol consumption (APA, 2000); OR = 2.26 to 2.7) rather than alcohol abuse (characterized by a pattern of negative consequences that result from alcohol use (APA, 2000); OR = 1.2 to 1.23; Buckner, Timpano, Zvolensky, Sachs-Ericsson, & Schmidt, 2008; Grant et al., 2005). Both retrospective and longitudinal studies have shown that when SAD and AUD co-occur, SAD typically precedes the onset of the AUD (Buckner, Schmidt, et al., 2008; Buckner, Timpano, et al., 2008; Buckner & Turner, 2009; Falk, Yi, & Hilton, 2008).

"Consistent with studies of adults, Kushner and Sher (1993) found that 43% of college freshmen with SAD met diagnostic criteria for an AUD while only 26% of college freshman without SAD met criteria for an AUD. Overall, however, research on the relationship between social anxiety and alcohol use among college students has revealed very mixed findings (see Morris et al. (2005), for a review). Some laboratory studies have demonstrated that socially anxious participants drink more in anticipation of both interaction (Higgins & Marlatt, 1975) and speech tasks (Kidorf & Lang, 1999), whereas others (e.g., Holroyd, 1978) have found that socially anxious students drink significantly less alcohol than non-socially anxious peers during informal laboratory-based “get togethers.” Survey studies of college students have either failed to find a relationship between social anxiety and alcohol consumption, or have found an inverse relationship between social anxiety and alcohol consumption (e.g., Buckner, Schmidt, & Eggleston, 2006; Gilles, Turk, & Fresco, 2006; Ham & Hope, 2006; Lewis et al., 2008). One possible reason for the lack of a positive relationship between social anxiety and alcohol use is that socially anxious students may avoid social situations and only use alcohol to cope with anxiety in social situations when they cannot be avoided (Norberg, Norton, & Olivier, 2009; Stewart, Morris, Mellings, & Komar, 2006).

"Despite the fact that many studies have found a negative relationship, or no relationship at all, between social anxiety and alcohol use, A.R. Schry, S.W. White / Addictive Behaviors 38 (2013) 2690–2706 2691many studies have found that social anxiety is positively associated with ARPs (e.g., Buckner, Ecker, & Proctor, 2011; Buckner & Heimberg, 2010; Buckner et al., 2006; Gilles et al., 2006; Norberg et al., 2009). A significant relationship between social anxiety and ARPs may be particularly important, because AUDs are defined by problems resulting from the use of alcohol rather than simply the quantity and frequency of use (Buckner et al., 2006). However, not all studies have found a significant relationship between social anxiety and ARPs (e.g., Ham, Zamboanga, Bacon, & Garcia, 2009; LaBrie, Pedersen, Neighbors, & Hummer, 2008)."

"Mean treatment results demonstrated in the present study obscure variations at the individual patient level. Some older patients with chronic pain may receive substantial benefit through psychological therapy, while others may not benefit. There is no evidence that the beneficial results identified at the completion of treatment persisted up to 6 months for outcomes other than pain reduction. There were too few studies reporting long-term outcomes to determine completely whether this finding was due to decreased power or to a tapering of treatment benefits over time.

"The observed benefits were strongest when delivered using group-based approaches. Potential mechanisms that could account for this finding include access to peer support, social facilitation of target behaviors, and public commitment to therapy goals.⁵² No other results of participant, intervention, or study characteristics were found. Treatment benefits were equally likely to occur in older men and women irrespective of age and duration of chronic pain."

"Although individual lifetime risk of chronic psychotic disorders such as schizophrenia, even in people who use cannabis regularly, is likely to be low (less than 3%), cannabis use can be expected to have a substantial effect on psychotic disorders at a population level because exposure to this drug is so common."

"First, the use of cannabis and rates of psychotic symptoms were related to each other, independently of observed/non-observed fixed covariates and observed time dynamic factors (Table 2). Secondly, the results of structural equation modeling suggest that the direction of causation is that the use of cannabis leads to increases in levels of psychotic symptoms rather than psychotic symptoms increasing the use of cannabis. Indeed, there is a suggestion from the model results that increases in psychotic symptoms may inhibit the use of cannabis."

"In terms of the model set out in the Introduction, the expected rise in diagnoses of schizophrenia and psychoses did not occur over a 10 year period. This study does not therefore support the specific causal link between cannabis use and the incidence of psychotic disorders based on the 3 assumptions described in the Introduction. This concurs with other reports indicating that increases in population cannabis use have not been followed by increases in psychotic incidence (Macleod et al., 2006; Arsenault et al., 2004; Rey and Tennant, 2002). However, it is not in line with findings of a rise in first admission rates for psychotic disorders among young people in Zurich following increases in cannabis availability and consumption (Ajdacic-Gross et al., 2007). One factor involved in this discrepancy may be the potency of the cannabis consumed, which varies considerably within Europe (EMCDDA, 2008). In addition, a Netherlands study found that high-potency cannabis obtained from ‘coffee shops’ led to higher levels of tetrahydrocannabinol (THC) in the blood, with young males aged 18–45 at particular risk for excessive consumption (Mensinga et al., 2006)."

"A review of the literature suggests that the majority of cannabis users, who use the drug occasionally rather than on a daily basis, will not suffer any lasting physical or mental harm. Conversely, as with other 'recreational' drugs, there will be some who suffer adverse consequences from their use of cannabis. Some individuals who have psychotic thought tendencies might risk precipitating psychotic illness. Those who consume large doses of the drug on a regular basis are likely to have lower educational achievement and lower income, and may suffer physical damage to the airways. They also run a significant risk of becoming dependent upon continuing use of the drug. There is little evidence, however, that these adverse effects persist after drug use stops or that any direct cause and effect relationships are involved."