The 12-Month Prevalence and Trends in DSM–IV Alcohol Abuse and Dependence

United States, 1991–1992 and 2001–2002

Bridget F. Grant, Ph.D., Ph.D.,a Deborah A. Dawson, Ph.D.,a Frederick S. Stinson, Ph.D.,a S. Patricia Chou, Ph.D.,a Mary C. Dufour, M.D., M.P.H.,b Roger P. Pickering, M.S.a

Background: Alcohol abuse and dependence can be disabling disorders, but accurate information is lacking on the prevalence of current Diagnostic and Statistical Manual, Fourth Edition (DSM–IV) alcohol abuse and dependence and how this has changed over the past decade. The purpose of this study was to present nationally representative data on the prevalence of 12-month DSM–IV alcohol abuse and dependence in 2001–2002 and, for the first time, to examine trends in alcohol abuse and dependence between 1991–1992 and 2001–2002. Methods: Prevalences and trends of alcohol abuse and dependence in the United States were derived from face-to-face interviews in the National Institute on Alcohol Abuse and Alcoholism’s (NIAAA) 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC: n = 43,093) and NIAAA’s 1991–1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES: n = 42,862). Results: Prevalences of DSM–IV alcohol abuse and dependence in 2001–2002 were 4.65 and 3.81 percent. Abuse and dependence were more common among males and among younger respondents. The prevalence of abuse was greater among Whites than among Blacks, Asians, and Hispanics. The prevalence of dependence was higher in Whites, Native Americans, and Hispanics than Asians. Between 1991–1992 and 2001–2002, abuse increased while dependence declined. Increases in alcohol abuse were observed among males, females, and young Black and Hispanic minorities, while the rates of dependence rose among males, young Black females, and Asian males. Conclusions: This study underscores the need to continue monitoring prevalence and trends and to design culturally sensitive prevention and intervention programs. KEY WORDS: DSM–IV alcohol abuse and dependence; Epidemiology; Secular trends

Introduction the most prevalent mental disorders in 2000). More than one-half of American the United States and are associated adults have a family member who has lcohol use disorders are among with substantial personal and societal or has had alcohol dependence (Dawson the most prevalent mental disor- costs (Goetzel et al., 2003; Roy-Byrne A ders worldwide and rank high et al., 2000; Sanderson and Andrews, as a cause of disability burden in most 2002; Stewart et al., 2003). These alcohol Reprinted from Drug and Alcohol regions of the world (World Health use disorders have enormous consequences Dependence 74(3). Bridget F. Grant, Organization, 2001). In 2003, the preva- not only for the health and welfare of Deborah A. Dawson, Frederick S. lence of alcohol use disorders was esti- those afflicted with the disorders, but Stinson, S. Patricia Chou, Mary C. mated at 1.7 percent globally, and these also for their families and children, their Dufour, and Roger P. Pickering. “The disorders accounted for 1.4 percent of employers, and the larger society. For 12-Month Prevalence and Trends in the total world disease burden (World example, approximately one in four chil- DSM–IV Alcohol Abuse and Depen- Health Organization, 2003). dren under 18 years old in the United dence: United States, 1991–1992 and Alcohol use disorders (i.e., alcohol States is exposed to alcohol abuse or 2001–2001,” pp. 223–234, 2004, abuse and dependence) also are among alcohol dependence in the family (Grant, with permission from Elsevier.

Vol. 29, No. 2, 2006 79 and Grant, 1998). Of the 11.1 million of Mental Disorders (DSM) of the alcohol abuse and dependence in victims of violent crime each year, almost American Psychiatric Association: the the United States assessed in the one in four, or 2.7 million, report that 1980 Epidemiologic Catchment Area National Institute on Alcohol Abuse the offender had been drinking prior to Survey (ECA) (Robins and Regier, 1991), and Alcoholism’s (NIAAA) 2001–2002 the crime (Greenfield, 1998). The eco­ the 1990–1992 National Comorbidity National Epidemiologic Survey on nomic costs of alcohol abuse and depen­ Survey (NCS) (Kessler et al., 1996), Alcohol and Related Conditions dence were $184.6 billion for 1998 and the 2001–2002 NCS–Replication (NESARC) (Grant et al., 2003b). This (the last year for which figures are avail­ Survey (NCS–R) (Kessler and Walters, report also presents, for the first time, able), or roughly $638 for every man, 2002). However, in addition to major trends in the prevalence of alcohol abuse woman, and child living in the United differences in survey designs that pre­ and dependence between 1991–1992 and States (Harwood, 1998). Thus, alcohol clude clear information about time 2001–2002 using the NIAAA NESARC use disorders impose a staggering, but trends, each of these studies was based and NIAAA’s 1991–1992 National potentially preventable, burden. on a different nomenclature—Diagnostic Longitudinal Alcohol Epidemiologic Despite the importance of accurate and Statistical Manual, Third Edition Survey (NLAES) (Grant et al., 1994) prevalence information on alcohol abuse (DSM–III) (American Psychiatric as the baseline. The 1991– 1992 NLAES and dependence, especially on changes Association, 1980); Diagnostic and and 2001–2002 NESARC are the only in the prevalence of these disorders Statistical Manual, Third Edition, Revised two national surveys conducted over over time, the information available to (DSM–III–R) (American Psychiatric the last decade to use consistent diag­ date has been surprisingly sparse. Time Association, 1987); and Diagnostic nostic definitions of alcohol abuse and (secular) trends in yearly per capita and Statistical Manual, Fourth Edition dependence, both of which were based alcohol consumption have been available (DSM–IV) (American Psychiatric on the most current psychiatric nomen­ from the founding days of the United Association, 1994)—making between- clature, the DSM–IV. States. However, these are not informa­ survey comparisons for the purpose of tive about whether time trends have time trend analysis impossible. occurred in lower or higher consumption Change or stability in the prevalence Methods levels, which have considerably different of alcohol abuse and dependence has public health implications. Time trend important research and public health data are also available on alcohol-related implications in a number of areas. For NESARC Sample research on the etiology of alcohol fatal automobile crashes, but these may The 2001–2002 NESARC is a repre­ reflect factors unrelated to alcohol that dependence (a complex disorder with both genetic and environmental influ­ sentative sample of the United States are not measured in large statistical sponsored by NIAAA that has been reporting systems. Similarly, time trends ences), understanding true changes in prevalence over time may be crucial in described in detail elsewhere (Grant et in alcohol-related liver cirrhosis mortal­ al., 2003b). The target population of ity may reflect the influence of causes interpreting familial aggregation and gene–phenotype associations (Rice et NESARC was the civilian noninstitu­ other than alcohol. Some papers on tionalized population, age 18 and older, time trends in drinking and alcohol- al., 2003). Since the distribution of risk or protective genotypes does not vary residing in the United States and the related problems have been published District of Columbia, including Alaska over the years (Greenfield et al., 2000; within a period as short as a decade, changing prevalence suggests changes and Hawaii. The sample included per­ Hasin et al., 1990; Midanik and Green­ sons living in households, the military field, 2000). However, these studies did in the level of environmental risk. Incorporation of this information into living off base, and the following group not cover abuse and dependence as quarters: boarding houses, rooming defined in the standard nomenclatures, the design of genetic studies may sharpen our ability to detect genetic effects. For houses, nontransient hotels and motels, and were based on very small samples. shelters, facilities for housing workers, Thus, trivial changes in numbers from policy and prevention efforts, accurate information on changes in potentially college quarters, and group homes. one survey to the next may have given Face-to-face personal interviews were rise to misleading impressions. Finally, vulnerable groups may highlight the need for focused planning on both the conducted with 43,093 respondents. three earlier surveys were conducted on national and local levels. The fact that The fieldwork for NESARC was con­ alcohol abuse and dependence as defined accurate data on time trends in the ducted by the United States Census in the Diagnostic and Statistical Manual prevalence of alcohol abuse and depen­ Bureau. The sampling frame response a Laboratory of Epidemiology and Biometry, Division of dence have not been available reflects a rate was 99 percent, the household Intramural Clinical and Biological Research, Department major gap in public health informa­ response rate was 89 percent, and the of Health and Human Services, National Institute on tion. The present study was designed, person response rate was 93 percent, Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD. in part, to address this gap and provide yielding an overall survey response rate the information. of 81 percent. b Office of the Director, Department of Health and Human Services, National Institute on Alcohol Abuse and Accordingly, this report presents The sampling frame of housing Alcoholism, National Institutes of Health, Bethesda, MD. data on the 12-month prevalence of units for NESARC is the Census

80 Alcohol Research & Health 12-Month Prevalence and Trends in DSM–IV Alcohol Abuse and Dependence

Supplementary Survey (C2SS), which important information on alcohol use Interviewers and Interviewer included 2,000 primary sampling units disorders in the United States during Training (PSUs) consisting of all 3,142 counties the last decade (Grant, 1997a,b, 2000; Experienced lay interviewers from the and county equivalents in the United Grant and Dawson, 1997). Fieldwork U.S. Census Bureau administered the States. The C2SS sample consisted of for NLAES also was conducted by the 655 PSUs. For NESARC, a sample was NLAES and NESARC interviews. On United States Census Bureau. Direct average, the 1,000 NLAES and 1,800 drawn from each of the C2SS’s 655 face-to-face interviews were administered PSUs in addition to a group quarters NESARC interviewers had 5 years’ to 42,862 respondents, age 18 and older, experience working on Census and sampling frame selected from the Census residing in the noninstitutionalized 2000 Group Quarters Inventory. other health-related surveys. NLAES population of the contiguous United Group quarter units were converted to used a paper-and-pencil survey instru­ housing unit equivalents and sampled States, including the District of Columbia. ment, whereas the NESARC survey together with other NESARC housing The household response rate for this sur­ instrument was computerized with units. To prevent potential respondent vey was 92 percent, and the sample per­ software that included built-in skip, logic, disclosure, smaller PSUs were collapsed son response rate was 98 percent, for and consistency checks. The NLAES so that the final NESARC data file an overall survey response rate of 90 and NESARC interviewers completed shows 435 PSUs. percent. a rigorous 5-day self-study at home and Oversampling of Blacks and Hispanics NLAES featured a complex multistage participated in a 5-day in-class training was accomplished at the design phase design. PSUs were stratified according session at one of the Bureau’s 12 regional of the survey. Oversampling increased to sociodemographic criteria and were offices. NESARC training supervisors the proportion of Hispanic and Black selected with probability proportional from each regional office also were households to approximately 20 per­ to their population size. From a sam­ required to complete the home study and to attend a centralized training session, cent each of the total sample. For each pling frame of approximately 2,000 where they completed the in-class training housing unit, one person was selected PSUs, 198 were selected for inclusion randomly from a roster of persons living under the direction of NIAAA sponsors in the NLAES sample. Within PSUs, and Census Field and Demographics in the household. At this stage in the geographically defined secondary sam­ survey design, young adults (ages 18–24) Surveys Division Headquarters Staff. pling units, referred to as segments, Regional supervisors recontacted a were oversampled at a rate of 2.25:1.00. were selected systematically for sample. The NESARC data were weighted random 10 percent of all the NLAES to reflect the probabilities of selection Oversampling of the Black population and NESARC respondents by telephone of PSUs within strata and for the selec­ was accomplished at this stage of sam­ for quality control purposes and to ver­ tion of housing units within the sample ple selection in order to secure ade­ ify the accuracy of the interviewer’s per­ PSUs. The data were also weighted: (1) quate numbers for analytic purposes. formance. During this quality control to account for the selection of one sam­ Within each household, one randomly interview, respondents were reasked a ple person from each household; (2) selected respondent, age 18 or older, set of 30 questions from different sections to account for oversampling of young was selected to participate in the sur­ of the interview to verify their answers. adults; (3) to adjust for nonresponse at vey. Oversampling of young adults, In addition, 2,657 NESARC respondents the household level and person level; ages 18–29, was accomplished at this were randomly selected to participate and (4) to reduce the variance arising stage of the sample selection. This sub­ in a face-to-face reinterview study after from selecting two PSUs to represent group of young adults was randomly completion of their NESARC interview. an entire stratum. The weighted data sampled at a ratio of 2.25:1.00. Each of these respondents was readmin­ were then adjusted to be representative The NLAES data were weighted: istered one to three complete sections of the civilian noninstitutionalized (1) to adjust for probabilities of selec­ of the NESARC survey instrument. population of the United States for tion; (2) to account for the selection of These interviews not only served as an a variety of socioeconomic variables one sample person from each house­ additional rigorous check on survey data quality, but they also formed the including region, age, sex, race, and hold; (3) to account for oversampling ethnicity using the 2000 Decennial basis of the test–retest reliability study young adults; and (4) to account for Census of Population and Housing. of the new modules of the survey nonresponse at the household and per­ instrument (Grant et al., 2003a). Thus, son levels. Once weighted, the data the field procedures in the two surveys NLAES Sample were adjusted to be representative of were rigorous and highly similar. The 1991–1992 NLAES is a nationally the United States civilian noninstitu­ tionalized population for a variety of representative survey of the United Diagnostic Assessment States population sponsored by NIAAA sociodemographic variables, including and has been described in more detail region, age, sex, race, and ethnicity The diagnoses of alcohol abuse and elsewhere (Grant et al., 1992, 1994). using the 1990 Decennial Census of dependence in NLAES and NESARC This survey has been a source of much Population and Housing. were made according to the DSM–IV

Vol. 29, No. 2, 2006 81 criteria. The diagnostic interview used Consistent with the DSM–IV, noses, and the associated prevalences to generate these diagnoses was the NIAAA NLAES and NESARC 12-month were recalculated. Once removed, the Alcohol Use Disorder and Associated diagnoses of alcohol abuse required a NESARC rates of abuse and dependence Disabilities Interview Schedule–DSM–IV respondent to meet at least one of four decreased by 0.30 percent and 0.36 (AUDADIS–IV: Grant et al., 2001), a criteria defined for abuse in the 12­ percent. These results indicate that any state-of-the-art structured diagnostic month period preceding the interview differences in the operationalizations of interview designed for use by lay inter­ and not concurrently meet criteria for alcohol abuse and dependence due to viewers who are not clinicians. Although DSM–IV alcohol dependence. To be the addition of the new NESARC the DSM–IV classification was not classified with a diagnosis of 12-month questions had a trivial impact on the published until the second quarter of 1994, alcohol dependence, respondents were comparability of NESARC and NLAES all of the specific diagnostic criteria for required to satisfy at least three of the definitions and were highly unlikely to DSM–IV alcohol abuse and dependence seven DSM–IV criteria for dependence account for the trends reported here. (American Psychiatric Association, 1991) during the last year. The withdrawal The reliability and validity of were known prior to the fieldwork for criterion of the alcohol dependence AUDADIS–IV alcohol abuse and NLAES and, therefore, were incorporated diagnosis was measured as a syndrome, dependence diagnoses are well docu­ into the AUDADIS–IV in their entirety. requiring at least two positive symptoms mented in numerous national and What was not known at the time was of withdrawal as defined in the DSM–IV international psychometric studies. which diagnostic criteria would be alcohol withdrawal diagnosis. These have been conducted in clinical, assigned to the abuse or dependence Both the NLAES and NESARC and particularly in general population categories. However, since all relevant versions of the AUDADIS–IV repre­ samples, the population for which it DSM–IV diagnostic criteria had been sented the duration criteria of both the was designed (Canino et al., 1999; incorporated into the AUDADIS–IV, alcohol abuse and dependence diagnoses. Cottler et al., 1997; Grant, 1992, 1996a, computer algorithms were designed to The duration criteria relate to specific b,c; Grant and Harford, 1989, 1990; produce diagnoses of abuse and depen­ abuse and dependence criteria, define Grant et al., 1995, 2003a; Harford and dence that accurately represented the the repetitiveness with which these Grant, 1994; Hasin and Paykin, 1999; placement of the criteria within abuse diagnostic criteria must occur in order Hasin et al., 1996, l997a,c,d, 2000; and dependence categories consistent to be positive, and are operationalized Muthen et al., 1993). Further, the psy­ by means of qualifiers, such as “recurrent,” chometric properties of the AUDADIS– with the final DSM–IV criteria. “often,” and “persistent.” Duration cri­ IV alcohol and drug modules were DSM–IV alcohol abuse and depen­ teria are not associated with all abuse examined in numerous countries in the dence are defined as maladaptive patterns and dependence criteria. In NLAES, World Health Organization–National of drinking, leading to clinically signifi­ the duration criteria were operationalized Institutes of Health Joint Project on cant impairment or distress. DSM–IV by asking respondents if a symptom Reliability and Validity (Chatterji et al., alcohol abuse is manifested by one or item had happened more than once. In 1997; Hasin et al., 1997b; Nelson et more of the following symptoms: NESARC, duration criteria associated al., 1999; Pull et al., 1997; Ustun et al., recurrent drinking resulting in failure to with abuse and dependence criteria were 1997; Vrasti et al., 1998). fulfill major role obligations; recurrent embedded directly into the symptom drinking in hazardous situations; recur­ questions (e.g., “more than once” want Analysis Procedures rent drinking-related legal problems; to stop or cut down on your drinking; and continued drinking despite recurrent have “periods” when you ended up As a result of the complex sample design social or interpersonal problems caused drinking more than you meant to). of NLAES and NESARC, specialized or exacerbated by drinking. DSM–IV The NESARC measure of depen­ software was required to estimate the alcohol dependence is defined by seven dence included two new questions, one standard errors of all prevalence estimates. diagnostic criteria: tolerance; the with­ to measure the “tolerance” criterion, and Standard errors presented here were drawal syndrome or drinking to relieve one to measure the “continued to drink estimated separately for NESARC and or avoid withdrawal symptoms; drinking despite persistent or recurrent physical NLAES using SUDAAN (Research larger amounts or for a longer period or psychological problems caused or Triangle Institute, 2002), a software than intended; persistent desire or exacerbated by drinking” criterion. The program that uses Taylor series lin­ unsuccessful attempts to cut down on abuse measure included one additional earization to adjust for complex survey drinking; spending a great deal of time question to operationalize the “hazardous sample design characteristics. For trend obtaining alcohol, drinking, or recover­ drinking” criterion. To determine the analyses, prevalence estimates, and ing from the effects of drinking; giving extent to which the addition of these standard errors that were derived sepa­ up important social, occupational, or questions might have influenced the rately for NLAES and NESARC were recreational activities in favor of drink­ comparability of NLAES and NESARC compared using t-tests designed for ing; and continued drinking despite a definitions, the questions were removed independent samples. In analyses com­ physical or psychological problem from the NESARC algorithms used to paring 12-month prevalences among caused or exacerbated by drinking. arrive at abuse and dependence diag­ subgroups of the population defined

82 Alcohol Research & Health 12-Month Prevalence and Trends in DSM–IV Alcohol Abuse and Dependence

by age, sex, and race–ethnicity using Age. Overall, each successively older dependence than Blacks (6.03 percent) NESARC, significance levels were age group demonstrated decreases in or Hispanics (6.92 percent). Also, at conservatively adjusted downwards to the prevalence of alcohol abuse. All age ages 30–44, Asians (0.44 percent) had P < 0.01 to account for multiple testing. differences were significant except the lower rates of dependence than all decline from ages 18–29 to 30–44, other race–ethnic groups. which was significant only for women Results and Hispanics. When examined within Age. A significant inverse relationship race–ethnic and sex groups, these age between rates of dependence across differences were less consistently signif­ each successively older age group was Prevalence of DSM–IV Alcohol icant. For example, the prevalence of found for the sample as a whole, and Abuse: 2001–2002 abuse among 30- to 44-year-olds was also when males and females were con­ significantly lower than that of 18- to sidered separately. The same significant The 12-month prevalence rates, stan­ 29-year-olds only among Hispanic males relationship of age to rates of dependence dard errors, and population estimates and Asian females. Rates of abuse for was found for White males and females. of DSM–IV alcohol abuse in 2001– 45- to 64-year-olds compared to 30- to In other race-by-gender groups, the 2002 are presented in Table 1. Overall, 44-year-olds and rates among the oldest prevalence of dependence for Black males the 12-month prevalence of abuse was age group (age 65 and older) compared was significantly lower among the old­ 4.65 percent, representing 9.7 million to the 45- to 64-year-old age group were est age group (1.10 percent) compared adult Americans. significantly lower among all males, all to the 45- to 64-year-old age group females, and Whites. Significant declines (3.98 percent). Also, the prevalence of Gender. Overall, rates of DSM–IV alcohol in prevalence between these age groups dependence for Hispanic males was sig­ abuse in 2001–2002 were substantially were also found when male and female nificantly lower in the 30- to 44-year­ and significantly higher for males (6.93 Whites were considered separately. old age group (5.33 percent) than in percent) than females (2.55 percent), a Among Blacks taken as a whole, and the youngest age group (9.58 percent) ratio of about 2.72. This large and sig­ among Black males and Black females, and significantly lower in the 45- to nificant gender difference also was found the rates of abuse were only significantly 64-year-old age group (2.06 percent) among Whites, Blacks, and Hispanics. lower among the oldest age group com­ than in the 30- to 44-year-old age group. Similar gender differences were found pared to the 45- to 64-year-old age group. among Asians and Native Americans, although these did not reach statistical Trends in DSM–IV Alcohol significance. The sex differential in the Prevalence of DSM–IV Alcohol Abuse Between 1991–1992 prevalence of DSM–IV alcohol abuse Dependence: 2001–2002 and 2001–2002 was significant within all age groups of The prevalence of 12-month DSM–IV The prevalence of 12-month DSM–IV the White, Black, and Hispanic sub­ alcohol dependence in 2001–2002 was alcohol abuse significantly increased groups except for Hispanics age 65 and 3.81 percent, representing 7.9 million over the last decade, from 3.03 percent older, where the gender difference was in Americans (Table 2). in 1991–1992 to 4.65 percent in 2001– the same direction but not significant. 2002 (Table 3). For the total sample, Gender and Race–Ethnicity. Although the increases were significant for males Race–Ethnicity. The prevalence of alcohol the rates of dependence for the total (4.67 percent to 6.93 percent) and abuse was significantly greater among sample were significantly greater for females (1.51 percent to 2.55 percent) Whites (5.10 percent) compared to males (5.42 percent) than females (2.32 and for each age–gender group except Blacks (3.29 percent), Asians (2.13 per­ percent), a ratio of approximately 2.34, 18- to 29-year-olds. cent), and Hispanics (3.97 percent). this difference was significant only for Between 1991–1992 and 2001– When race–ethnicity was addressed by Whites, Blacks, and Hispanics when 2002, the prevalence of abuse increased gender, White female rates significantly sex differences were assessed within among all race–ethnic groups except exceeded those of their Black, Asian, each race–ethnic subgroup of the pop­ Native Americans. The increases were and Hispanic counterparts, but White ulation. Whites (3.83 percent), Native significant among Whites, Blacks, and male rates significantly exceeded only Americans (6.35 percent), and Hispanics Hispanics. Further, the increases were those of Black and Asian males. The (3.95 percent) had a significantly higher significant within both genders in each prevalence of abuse was significantly prevalence of dependence than Asians of these three race–ethnic groups. greater among Native Americans (5.75 (2.41 percent), but no significant dif­ Among Whites, there was a significant percent) and Hispanics (3.97 percent) ferences were found in the rates of increase in the rate of abuse among all compared to Asians (2.13 percent), but dependence between any of the other male and female age groups, except 18­ when broken down by gender, only the race–ethnic groups. There were a num­ to 29-year-olds. Among Black males, Hispanic male rate (6.21 percent) was ber of differences at the subgroup level; there were significant increases in the significantly greater than the Asian male for example, at ages 18–29, Whites prevalence of abuse among all age rate (3.20 percent). (10.71 percent) had higher rates of groups. Among Black females, alcohol

Vol. 29, No. 2, 2006 83 Table 1 Twelve-Month Prevalence of DSM–IV Alcohol Abuse by Age, Sex, and Race–Ethnicity: 2001–2002

Male Female Total Sociodemographic Population Population Population Characteristic % S.E. Estimatea % S.E. Estimatea % S.E. Estimatea

Total Total 6.93 0.28 6906 2.55 0.16 2762 4.65 0.18 9668 18–29 9.35 0.61 2110 4.57 0.39 1041 6.95 0.39 3151 30–44 8.69 0.49 2742 3.31 0.28 1080 5.95 0.31 3822 45–64 5.50 0.43 1719 1.70 0.20 566 3.54 0.25 2286 65+ 2.36 0.32 335 0.38 0.11 75 1.21 0.15 410

White Total 7.45 0.33 5276 2.92 0.19 2236 5.10 0.21 7511 18–29 10.19 0.81 1405 5.56 0.54 777 7.86 0.50 2182 30–44 10.10 0.63 2166 4.13 0.38 902 7.09 0.40 3068 45–64 5.97 0.51 1425 2.02 0.26 499 3.96 0.30 1925 65+ 2.38 0.35 279 0.36 0.10 58 1.21 0.16 336

Black Total 5.71 0.58 574 1.41 0.19 182 3.29 0.30 756 18–29 6.92 1.28 166 2.10 0.45 68 4.28 0.67 254 30–44 7.04 0.95 238 1.51 0.30 65 3.95 0.46 302 45–64 4.48 0.74 132 1.25 0.37 47 2.66 0.40 178 65+ 1.79 0.59 19 0.12 0.12 2 .78 0.25 21

Native Americanb Total 7.47 1.65 157 4.18 1.25 97 5.75 1.02 253 18–29 15.25 5.68 56 6.68 3.34 33 10.35 3.11 89 30–44 7.67 3.00 54 6.52 3.01 49 7.07 2.13 102 45–64 4.85 2.12 39 0.00 0.00 0 2.57 1.14 39 65+ 3.59 2.49 8 4.12 4.00 15 3.91 2.63 24

Asianc Total 3.20 0.79 140 1.13 0.41 53 2.13 0.46 193 18–29 4.77 1.81 63 3.89 1.38 47 4.35 1.25 110 30–44 4.22 1.54 64 0.23 0.22 4 2.18 0.79 68 45–64 1.13 0.78 13 0.20 0.20 4 0.61 0.32 16 65+ 0.00 0.00 0 0.00 0.00 0 0.00 0.00 0

Hispanic/Latino Total 6.21 0.50 759 1.65 0.23 195 3.97 0.30 953 18–29 9.08 1.07 400 3.04 0.63 116 6.28 0.63 516 30–44 4.88 0.59 219 1.46 0.33 61 3.23 0.37 281 45–64 4.35 0.84 111 0.63 0.36 17 2.43 0.39 128 65+ 3.69 1.62 29 0.00 0.00 0 1.56 0.66 29

a Population counts are in thousands. b Includes American Indians and Alaska Natives. c Includes Native Hawaiians and other Pacific Islanders.

84 Alcohol Research & Health 12-Month Prevalence and Trends in DSM–IV Alcohol Abuse and Dependence

Table 2 Twelve-Month Prevalence of DSM–IV Alcohol Dependence by Age, Sex, and Race–Ethnicity: 2001–2002

Male Female Total Sociodemographic Population Population Population Characteristic % S.E. Estimatea % S.E. Estimatea % S.E. Estimatea

Total Total 5.42 0.21 5397 2.32 0.13 2515 3.81 0.14 7912 18–29 13.00 0.68 2934 5.52 0.40 1256 9.24 0.41 4190 30–44 4.98 0.34 1570 2.61 0.26 851 3.77 0.23 2422 45–64 2.67 0.25 837 1.15 0.17 383 1.89 0.15 1220 65+ 0.39 0.11 56 0.13 0.06 25 0.24 0.06 80

White Total 5.41 0.26 3832 2.37 0.16 1811 3.83 0.16 5642 18–29 15.10 0.91 2083 6.38 0.57 891 10.71 0.57 2974 30–44 5.13 0.44 1101 2.84 0.33 621 3.98 0.28 1722 45–64 2.56 0.30 611 1.15 0.21 285 1.84 0.18 895 65+ 0.32 0.11 37 0.08 0.05 13 0.18 0.05 50

Black Total 5.09 0.52 512 2.39 0.31 309 3.57 0.29 821 18–29 8.75 1.53 235 3.79 0.74 124 6.03 0.82 359 30–44 4.40 0.81 149 2.53 0.43 108 3.36 0.42 257 45–64 3.98 0.76 117 1.74 0.54 65 2.72 0.43 182 65+ 1.10 0.58 12 0.71 0.47 12 0.87 0.36 23

Native Americanb Total 8.38 1.84 176 4.49 1.32 104 6.35 1.17 280 18–29 15.96 5.61 59 8.73 3.62 43 11.83 3.31 102 30–44 10.94 3.43 77 5.77 3.16 43 8.27 2.32 120 45–64 5.11 2.33 41 2.53 1.70 18 3.90 1.48 59 65+ 0.00 0.00 0 0.00 0.00 0 0.00 0.00 0

Asianc Total 3.56 0.74 1.56 1.34 0.49 63 2.41 0.38 218 18–29 10.22 2.33 135 4.27 1.81 51 7.39 1.15 186 30–44 0.28 0.29 4 0.59 0.44 9 0.44 0.27 14 45–64 1.42 0.89 16 0.15 0.14 2 0.72 0.41 18 65+ 0.00 0.00 0 0.00 0.00 0 0.00 0.00 0

Hispanic/Latino Total 5.90 0.72 721 1.94 0.27 229 3.95 0.44 950 18–29 9.58 1.33 422 3.85 0.60 147 6.92 0.80 569 30–44 5.33 1.04 240 1.65 0.53 69 3.55 0.72 309 45–64 2.06 0.63 53 0.46 0.19 13 1.23 0.31 65 65+ 0.85 0.86 7 0.00 0.00 0 0.36 0.36 7

a Population counts are in thousands. b Includes American Indians and Alaska Natives. c Includes Native Hawaiians and other Pacific Islanders.

Vol. 29, No. 2, 2006 85 abuse increased somewhat among all over the past decade, neither increasing has not previously attracted attention ages, although the increase reached sig­ nor decreasing. as being at elevated risk for alcohol use nificance only for the 45- to 64-year­ disorders. Consistent with earlier pat­ old age group. Among Hispanics, the terns, respondents in the youngest age rates of alcohol abuse increased slightly Discussion groups (ages 18–29 and 30–44) con­ in all age groups from 2001–2002 tinue to have the highest prevalence of compared to 1991–1992 for each gender, The total prevalence of 12-month DSM– alcohol abuse and dependence. Taken although the increase reached signifi­ IV alcohol abuse and dependence in together, these results highlight the cance only among males ages 18–29. 1991–1992 was 7.41 percent, represent­ need to strengthen existing prevention Among Asians, increases in abuse reached ing 13.8 million adult Americans. In efforts and to develop new programs significance only for 18- to 29-year-old 2001–2002, this prevalence rose to designed with the sex and race–ethnic females and all persons age 65 and 8.46 percent, representing 17.6 million differentials observed in 2001–2002 in older, although nonsignificant increases adult Americans. Given the harmful mind. Moreover, these findings under­ occurred in several other age groups. effects of alcohol use disorders on the score the need for early prevention pro­ Among Native Americans, a significantly afflicted individuals as well as on those grams among all youth, regardless of increased rate of abuse was found only around them and society as a whole, sex or race–ethnicity. among 45- to 64-year-old males. alcohol use disorders continue to repre­ Male and female rates of abuse have sent a substantial public health problem. converged over the last decade. Overall, The high degree of comparability the male to female ratio for alcohol abuse Trends in DSM–IV Alcohol between NLAES and NESARC defini­ declined from 3.09 in 1991–1992 to Dependence Between 1991–1992 tions of alcohol abuse and dependence 2.72 in 2001–2002. The narrowing in and 2001–2002 made it possible, for the first time, to the gap between male and female rates The prevalence of DSM–IV alcohol accurately determine trends in these of abuse also was observed among dependence significantly decreased, disorders over the course of a decade. Whites (2.98–2.55), Native Americans from 4.38 percent to 3.81 percent, over During this time, the prevalence of alco­ (2.97–1.79), Asians (3.5 1–2.83), and the past decade (Table 4). Rates signifi­ hol dependence significantly declined, Hispanics (4.77–3.76), but not among cantly decreased among males (6.33 from 4.38 percent to 3.81 percent. With Blacks. Although convergence in the percent to 5.42 percent), but remained regard to specific groups, the prevalence rates of abuse was found for most age of alcohol dependence decreased over groups among Whites and Hispanics, relatively unchanged among females. the past decade in males while remaining it was only observed in the youngest Rates also significantly decreased among stable in females, resulting in a some­ age groups (ages 18–29) among Asians Whites (4.35 percent to 3.83 percent) what smaller current gender difference (4.46–1.23) and Native Americans and Hispanics (5.78 percent to 3.95 than had been found previously. (3.40–2.28). percent) but remained relatively stable Dependence also decreased among In contrast, a male–female conver­ among Blacks, Native Americans, and Whites and Hispanics. However, in gence in the prevalence of dependence Asians. contrast, there was a significant increase was found among the 30- to 44-year­ When prevalence rates within sub­ in the prevalence of alcohol abuse, from old (2.46–1.91) and 45- to 64-year-old groups of the population were examined, 3.03 percent in 1991–1992 to 4.65 (2.85–2.32) age groups in the total significant increases in dependence were percent in 2001–2002. This increase sample, a pattern that also was observed observed for 18- to 29-year-old Black was apparent in both genders and was among Whites of those ages. Conver­ females (2.14 percent to 3.79 percent) especially marked in young Black and gence was found among all Blacks and and 18- to 29-year-old Asian males (4.09 Hispanic minorities. Hispanics and particularly among 18­ percent to 10.22 percent). Significant The first-time availability of trend to 29-year-old Blacks (3.99–2.31) and decreases in the rates of dependence data allows constant as well as emerg­ Hispanics (5.20–2.49). Over the next occurred among White males (6.16 ing high-risk subgroups to be identified decade, the design and implementation percent to 5.41 percent), Whites age with much greater clarity and specificity of programs targeted at females, espe­ 65 and older (0.38 percent to 0.18 per­ than in the past. For example, Whites, cially 30- to 44-year-old Whites and cent), 30- to 44-year-old Asian males Native Americans, and males remain 18- to 29-year-olds of each race–ethnic (3.02 percent to 0.28 percent), Hispanic high-risk subgroups for abuse in 2001– subgroup, can go a long way in reduc­ males (9.40 percent to 5.90 percent), 2002, while rates in the other subgroups ing the convergence observed among 18- to 29-year-old Hispanic males increased to approach those of these the male and female rates of alcohol (15.44 percent to 9.58 percent), 45- stably high-risk groups. Among the sta­ abuse and dependence, that is, in the to 64-year-old Hispanic males (6.70 ble high-risk subgroups for dependence phenomenon of women’s rates rising to percent to 2.06 percent), and all 45- to were young adults, especially Whites match those of men. 64-year-old Hispanics (3.65 percent to and Native Americans. A group that One of the interesting results of the 1.23 percent). All other subgroup rates showed an especially sharp increase was trend analysis was that rates of alcohol of alcohol dependence remained stable young adult Asian males, a group that dependence had declined slightly,

86 Alcohol Research & Health 12-Month Prevalence and Trends in DSM–IV Alcohol Abuse and Dependence

Table 3 Trends in the 12-Month Prevalence of DSM–IV Alcohol Abuse by Age, Sex, and Race–Ethnicity: 1991–1992 and 2001–2002

Male Female Total Sociodemographic NLAES NESARC NLAES NESARC NLAES NESARC Characteristic (1991–1992) (2001–2002) (1991–1992) (2001–2002) (1991–1992) (2001–2002)

Total Total 4.67 6.93a 1.51 2.55a 3.03 4.65a 18–29 9.26 9.35 3.83 4.57 6.54 6.95 30–44 4.58 8.69a 1.50 3.31a 3.02 5.95a 45–64 2.38 5.50a 0.38 1.70a 1.35 3.54a 65+ 0.55 2.36a 0.04 0.38a 0.25 1.21a

White Total 5.09 7.45a 1.71 2.92a 3.33 5.10a 18–29 10.75 10.19 4.83 5.56 7.83 7.86 30–44 5.16 10.10a 1.68 4.13a 3.41 7.09a 45–64 2.55 5.97a 0.44 2.02a 1.47 3.96a 65+ 0.52 2.38a 0.04 0.36a 0.24 1.21a

Black Total 2.38 5.71a 0.73 1.41a 1.46 3.29a 18–29 3.38 6.92b 1.27 2.10 2.44 4.28a 30–44 2.54 7.04a 1.00 1.51 1.70 3.95a 45–64 1.19 4.48a 0.02 1.25a 0.54 2.66a 65+ 0.00 1.79a 0.00 0.12 0.00 0.78a

Native American Total 12.80 7.47 4.31 4.18 8.14 5.75 18–29 27.88 15.25 8.19 6.68 17.59 10.35 30–44 2.64 7.67 3.73 6.52 3.22 7.07 45–64 0.00 4.85b 0.00 0.00 0.00 2.57b 65+ 0.00 3.59 0.00 4.12 0.00 3.91

Asian Total 1.65 3.20 0.47 1.13 1.08 2.13 18–29 3.30 4.77 0.74 3.89b 2.02 4.35 30–44 1.67 4.22 0.21 0.23 0.93 2.18 45–64 0.00 1.13 0.66 0.20 0.30 0.61 65+ 0.00 0.00 0.00 0.00 0.00 0.00

Hispanic/Latino Total 4.15 6.21b 0.87 1.65b 2.52 3.97a 18–29 5.85 9.08b 1.56 3.04 3.71 6.28a 30–44 3.30 4.88 0.86 1.46 2.15 3.23 45–64 3.08 4.35 0.13 0.63 1.60 2.43 65+ 2.90 3.69 0.00 0.00 1.16 1.56

a P < 0.01. b P < 0.05.

Vol. 29, No. 2, 2006 87 Table 4 Trends in the 12-Month Prevalence of DSM–IV Alcohol Dependence by Age, Sex, and Race–Ethnicity: 1991–1992 and 2001–2002

Male Female Total Sociodemographic NLAES NESARC NLAES NESARC NLAES NESARC Characteristic (1991–1992) (2001–2002) (1991–1992) (2001–2002) (1991–1992) (2001–2002)

Total Total 6.33 5.42a 2.58 2.32 4.38 3.81a 18–29 12.81 13.00 6.01 5.52 9.40 9.24 30–44 6.07 4.98b 2.47 2.61 4.25 3.77 45–64 3.19 2.67 1.12 1.15 2.12 1.89 65+ 0.63 0.39 0.23 0.13 0.39 0.24

White Total 6.16 5.41b 2.67 2.37 4.35 3.83b 18–29 13.59 15.10 7.28 6.38 10.48 10.71 30–44 6.12 5.13 2.43 2.84 4.27 3.98 45–64 2.80 2.56 1.03 1.15 1.89 1.84 65+ 0.57 0.32 0.24 0.08 0.38 0.18b

Black Total 5.86 5.09 2.21 2.39 3.84 3.57 18–29 8.54 8.75 2.14 3.79b 5.07 6.03 30–44 6.13 4.40 3.26 2.53 4.57 3.36 45–64 4.05 3.98 1.95 1.74 2.89 2.72 65+ 0.83 1.10 0.00 0.71 0.32 0.87

Native American Total 11.00 8.38 7.38 4.49 9.01 6.35 18–29 13.34 15.96 14.67 8.73 14.03 11.83 30–44 8.85 10.94 2.15 5.77 5.32 8.27 45–64 4.61 5.11 4.73 2.53 4.68 3.90 65+ 25.39 0.00 0.00 0.00 9.75 0.00

Asian Total 3.06 3.56 1.41 1.34 2.26 2.41 18–29 4.09 10.22b 3.77 4.27 3.93 7.39 30–44 3.02 0.28b 0.00 0.59 1.50 0.44 45–64 2.90 1.42 0.73 0.15 1.90 0.72 65+ 0.00 0.00 0.00 0.00 0.00 0.00

Hispanic/Latino Total 9.40 5.90a 2.15 1.94 5.78 3.95b 18–29 15.44 9.58b 2.97 3.85 9.21 6.92 30–44 6.56 5.33 2.70 1.65 4.74 3.55 45–64 6.70 2.06b 0.63 0.46 3.65 1.23b 65+ 0.00 0.85 0.62 0.00 0.37 0.36

a P < 0.01. b P < 0.05.

88 Alcohol Research & Health 12-Month Prevalence and Trends in DSM–IV Alcohol Abuse and Dependence

whereas rates of abuse had increased. abuse may be quite different from those Therefore, achieving an understanding The decrease in the rate of dependence associated with alcohol dependence. of the changes in prevalence among is not surprising, in that most measures Identifying these drinking patterns is a minority young adults over time will of alcohol consumption have also potentially important area for future require further research, but is an declined slightly over the same period. research. The observation that alcohol important public health priority. The National Health Interview Survey abuse is most prevalent among the What is clear is that no single envi­ found that the percentage of heavy youngest age groups underscores the ronmental factor can explain the drinkers fell from 7.9 percent to 7.1 need for continued research on drink­ increases in alcohol abuse and depen­ percent, and the percentage of adults ing pattern trajectories that, for the dence prevalence observed in this study who drank 5+ drinks monthly or more most part, are initiated in adolescence. among certain minority subgroups of often fell from 15.6 percent to 14.4 One of the most striking findings the population. Numerous environ­ percent (National Center for Health from the trend analysis of 12-month mental factors, including social and Statistics, 2002). Earlier data from the DSM–IV alcohol abuse between 1991– economic factors, are all likely to serve National Alcohol Surveys conducted in 1992 and 2001–2002 was that rate of as mediators of the observed temporal 1990 and 1995 showed stable rates of abuse had not increased among White or secular rate changes. With regard to drinking, any binge drinking, and fre­ young adults (ages 18–29) but had putative economic factors, there is a clear quent binge drinking during that period increased among minority young adults, need for additional studies to ascertain (Greenfield et al., 2000). Similarly, the specifically Black males, Asian females, how changes in alcoholic beverage National Household Survey on Drug and Hispanic males. Similarly, the prices, taxes, and availability affect the Abuse (Substance Abuse and Mental prevalence of 12-month DSM–IV alco­ prevalence of alcohol use disorders among Health Services Administration, 1995, hol dependence significantly increased race–ethnic and other subgroups of the 2002) found little change between 1992 among Black females and Asian males population. Historical and cultural fac­ and 2001 in the rates of any past-month in the 18- to 29-year-old age group, tors that shape the life history of various drinking (47.8 percent and 48.3 percent, while no such increases were noted for race–ethnic minorities in the United respectively) and heavy past-month White, Native American, and Hispanic States are potentially equally important drinking (5+ drinks on the same occasion young adults. It should also be noted in understanding the observed secular on each of 5 or more days in the past the prevalence rates of abuse and depen­ changes. Within this context, future 30 days, 5.0 percent and 5.7 percent, dence among Native American young research will need to more fully address respectively). adults are quite high, even though these the extraordinary heterogeneity within What is surprising, then, is that the rates have not significantly increased race–ethnic groups in the search for the prevalence of alcohol abuse increased in over the last decade. explanations of why rates of alcohol the face of slightly declining rates of heavy The reasons for the rise of alcohol abuse and dependence have increased drinking. One possible factor underly­ abuse and dependence among these among some minority young adults as ing this could be changes in drinking minority young adults are not known. opposed to White young adults. For norms as heavy consumption has Recently, researchers have highlighted example, rates of heavy drinking, abuse, declined. With the decrease in heavy the impact on drinking patterns, abuse, and dependence differ vastly among drinking, social attitudes may have and dependence of acculturative stress Chinese Americans, Japanese Americans, become more negative toward drinking felt by immigrants who are faced with Cambodian Americans, Korean at levels that were previously accepted. adapting to a new society. Socioeconomic Americans, and Filipino Americans If so, this could have led to increased stress experienced by race–ethnic (Price et al., 2002). Similar differentials social/interpersonal conflict about drink­ minorities because of inadequate finan­ have also been found among Mexican ing even though overall levels have cial resources and limited social class Americans, Cuban Americans, and declined. Since social/interpersonal standing, and stress or tensions that Puerto Rican Americans and among problems related to drinking constitute minorities experience as a result of dis­ some of the over 300 different tribal one of the DSM–IV criteria for alcohol crimination have also been implicated and language groups that define Native abuse, such interpersonal conflict would (Al-Issa, 1997). Alternatively, the grow­ Americans and Alaska Natives living be reflected in the increased prevalence ing numbers of minority youth attending in the United States (Aguirre-Molina of alcohol abuse. The possibility of such college may increasingly have exposed and Caetano, 1994; Beauvais, 1998). environmental influences on alcohol them to the risks of heavy drinking Understanding and working effectively abuse as distinct from dependence has commonly noted among college stu­ with cultural beliefs and practices of long been recognized (Rounsaville et dents (U.S. Department of Education, individuals from diverse race–ethnic al., 1986). 2001). Other researchers have argued backgrounds will be of paramount Alternatively, alcohol abuse may be that alcohol advertising targeting Black importance in the development of related to complex drinking patterns, communities has promoted heavier successful intervention and prevention not measured in previous trend studies drinking, particularly of malt liquor, programs. of heavy drinking. Drinking patterns among young adults of this group At present, research aimed at identi­ related to the development of alcohol (Hacker et al., 1987; Herd, 1993). fying independent environmental risk

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