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    ABSTRACT: Community prevalence rates of alcohol use disorders (AUDs) provided by epidemiological studies using DSM-based diagnostic criteria pose several challenges: the rates appear implausibly high to many epidemiologists; they do not converge across similar studies; and, due to low service utilization by those diagnosed as disordered, they yield estimates of unmet need for services so high that credibility for planning purposes is jeopardized. For example, two early community studies using DSM diagnostic criteria, the Epidemiologic Catchment Area Study (ECA) and the National Comorbidity Survey (NCS), yielded lifetime AUD prevalence rates of 14 and 24%, respectively, with NCS unmet need for services 19% of the entire population. Attempts to address these challenges by adding clinical significance requirements to diagnostic criteria have proven unsuccessful. Hypothesizing that these challenges are due to high rates of false-positive diagnoses of problem drinking as AUDs, we test an alternative approach. We use the harmful dysfunction (HD) analysis of the concept of mental disorder as a guide to construct more valid criteria within the framework of the standard out-of-control model of AUD. The proposed HD criteria require harm and dysfunction, where harm can be any negative social, personal, or physical outcome, and dysfunction requires either withdrawal symptoms or inability to stop drinking. Using HD criteria, ECA and NCS lifetime prevalences converge to much-reduced rates of 6 and 6.8%, respectively. Due to higher service utilization rates, NCS lifetime unmet need is reduced to 3.4%. Service use and duration comparisons suggest that HD criteria possess increased diagnostic validity. Moreover, HD criteria eliminate 90% of transient teenage drinking from disorder status. The HD version of the out-of-control model thus potentially resolves the three classic prevalence challenges while offering a more rigorous approach to distinguishing AUDs from problematic drinking.
    Frontiers in Psychiatry 10/2014; 5:10.
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    ABSTRACT: Background: This paper provides results from a pilot study focused on assessing early-stage effectiveness and usability of a smartphone-based intervention system that provides a stand-alone, self-administered intervention option, the Location-Based Monitoring and Intervention for Alcohol Use Disorders (LBMI-A). The LBMI-A provided numerous features for intervening with ongoing drinking, craving, connection with supportive others, managing life problems, high-risk location alerting, and activity scheduling. Methods: Twenty-eight participants, ranging in age from 22 to 45, who met criteria for an alcohol use disorder used an LBMI-A–enabled smartphone for 6 weeks. Results: Participants indicated the LBMI-A intervention modules were helpful in highlighting alcohol use patterns. Tools related to managing alcohol craving, monitoring consumption, and identifying triggers to drink were rated by participants as particularly helpful. Participants also demonstrated significant reductions in hazardous alcohol use while using the system (56% of days spent hazardously drinking at baseline vs. 25% while using the LBMI-A) and drinks per day diminished by 52%. Conclusions: Implications for system improvement as well as suggestions for designing ecological momentary assessment and intervention systems for substance use disorders are discussed.
    Substance Abuse 05/2014; 35(2). · 1.62 Impact Factor
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    ABSTRACT: Objective Current knowledge regarding psychiatric disorders and crime in youth is limited to juvenile justice and community samples. This study examined relationships between psychiatric disorders and self-reported crime involvement in a sample of youth representative of the US population. Method The National Comorbidity Survey-Adolescent Supplement (N=10,123; ages 13-17; 2001-2004) was used to examine the relationship between lifetime DSM-IV-based diagnoses, reported crime (property, violent, other), and arrest history. Logistic regression compared the odds of reported crime involvement with specific psychiatric disorders to those without any diagnoses, and examined the odds of crime by psychiatric comorbidity. Results Prevalence of crime was 18.4%. Youth with lifetime psychiatric disorders, compared to no disorders, had significantly greater odds of crime, including violent crime. For violent crime resulting in arrest, conduct disorder (CD; OR=57.5; 95% CI=30.4,108.8), alcohol use disorders (OR=19.5; 95% CI=8.8,43.2), and drug use disorders (OR=16.1; 95% CI=9.3,27.7) had the greatest odds with similar findings for violent crime with no arrest. Psychiatric comorbidity increased the odds of crime. Youth with 3 or more diagnoses (16.0% of population) accounted for 54.1% of those reporting arrest for violent crime. Youth with at least 1 diagnosis committed 85.8% of crime, which was reduced to 67.9% by removing those with CD. Importantly, 88.2% of youth with mental illness report never committing any crime. Conclusion Our findings highlight the importance of improving access to mental health services for youthful offenders in community settings given the substantial associations found between mental illness and crime in this nationally representative epidemiological sample.
    Journal of the American Academy of Child & Adolescent Psychiatry 08/2014; · 6.35 Impact Factor