1 Metropolitan Autonomous University-Xochimilco, Mexico City, Mexico, 2 Division of Epidemiological and Psychosocial Research, National Institute of Psychiatry, Calz. Mexico-Xochimilco No.101, Col. San Lorenzo Huipulco, CP.14370, Mexico and 3 Alcohol Research Group, Berkeley CA, USA
* Author to whom correspondence should be addressed: Tel.: +52 5 6552811 (ext. 318); Fax: +52 5 5133446; E-mail: guibor{at}imp.edu.mx
(Received 25 January 2005; first review notified 25 February 2005; in revised form 11 March 2005; accepted 13 March 2005)
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ABSTRACT |
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INTRODUCTION |
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In this report, we further explore the relationship between AUD and SUD among ED patients. Our goal here is to report a casecontrol study of AUD and SUD, according to the international classification of diseases 10 (ICD-10) (World Health Organization, 1992) and diagnostic and statistics manual of mental disorders-IV (DSM-IV) (American Psychiatric Association, 1994
) criteria, and the risk of non-fatal injuries in one ED in Mexico City, Mexico.
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SUBJECTS AND METHODS |
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General population sample
The Mexican national comorbidity survey (M-NCS) presented here is part of the WHO-world mental health surveys consortium (Demyttenaere et al., 2004). All interviews were carried out face to face in the homes of respondents by trained lay interviewers. Interviews were conducted after a careful description of the study goals was given and informed consent was obtained. No financial incentive was given for respondents. The M-NCS is based on a stratified, multistage area probability sample of persons aged 18 to 65 years in the non-institutionalized population living in urban areas (population
2500) of Mexico. About 75% of the Mexican population has been defined as urban. Data collection took place from September 2001 through May 2002. The response rate for the survey was 76.6%. More details about the methods of this survey are available in Medina-Mora (Medina-Mora et al., 2003
). One of the cities selected for the study was the metropolitan area of Mexico City. All results presented below are based on a total of 1131 respondents from Mexico City.
ED survey
A sample of adult patients, 18 years, admitted to the ED of a public hospital in the south of Mexico City was drawn from ED admission forms, which reflected consecutive patient arrival in the ED over a six and a half-week period (January and February 2002). All eligible patients from ED logs and medical records seen in the ED during a 24-h period were approached to be interviewed (with informed consent) as soon as possible after admission to the ED. Patients with severe mental disorders and patients in police custody were not included. Patients who were too severely injured to be interviewed in the ED were followed into the hospital and interviewed after their condition had stabilized. No financial incentive was given for respondents. Details of the methods and characteristics of the sample can be consulted elsewhere (Borges et al., 2004
).
During the data collection period a total of 744 patients were approached, of whom 39 (5.2%) did not participate. The main reason for non-participation was refusal (2.2%) and patients being transferred before they could be interviewed (1.7%). In order to match the age range of the ED patients with the population sample, we restricted our population of patients to a total of 653 injured cases, aged 1865 years.
Measures
A series of comparable questions were asked to obtain information on demographic variables and on alcohol and substance use in both surveys. Respondents who reported alcohol use and substance use (marijuana, cocaine, tranquilizers, amphetamines, others) use were further assessed for AUDs and SUDs.
Diagnostic: The instrument used was the world mental health version of the composite international diagnostic interview (WMH-CIDI) (Robins et al., 1988 Kessler and Ustun, 2004
). In the general population sample, this structured diagnostic interview was administered using a laptop computer version. In the ED sample, all interviews were performed using the paper and pencil version of the same modules of AUDs and SUDs. Our focus here is on either ICD-10 or DSM-IV AUDs and SUDs. For the purpose of this paper, all questions were related to the presence of symptoms during the past 12 months. A patient was considered positive for alcohol dependence if positive in three of the six domains of ICD-10 and/or three of the seven domains of DSM-IV. Patients were considered positive for alcohol abuse if positive on any one of the consequences of alcohol use items in either diagnostic scheme. A parallel series of questions on SUDs were also asked and respondents were classified with substance abuse and substance dependence (SUD) with similar criteria.
Analysis
Data are reported on the association of AUD and SUD with injury in the ED. As a result of the complex sample design and weighting used in the M-NCS, estimates of SEs for proportions were obtained by the Taylor series linearization method using the STATA software (STATA CORP, 2003). Logistic regression analysis (Hosmer and Lemeshow, 2000
) was performed to study demographic correlates and the impact of AUD and SUD on injury. Estimates of SEs of odds ratios (ORs) from logistic regression coefficients were also obtained by STATA, and 95% confidence intervals (CI) have been adjusted to design effects.
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RESULTS |
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DISCUSSION |
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The prevalence of SUDs has been rarely reported in ED populations (Cottrol and Frances, 1993). A larger ED study reported a prevalence of 17.7% of DSM-III-R current (6 months) drug use diagnoses and a large current comorbid prevalence of alcohol and drug use disorders (8.3%) (Soderstrom et al., 1997
). A study conducted in seven Tennessee general hospitals EDs, found that 4% of patients met the DSM-IV current drug dependence criteria and 27% were assessed as requiring substance abuse treatment (Rockett et al., 2003
). We found a lower prevalence of drug use disorders in this sample of injured patients, possibly owing to the lower baseline prevalence of substance dependence in Mexico when compared with the US (Vega et al., 2002
) and, in part, on account of this being a level 1 trauma centre.
The prevalence of drug use in combination with alcohol has also been found not to be inconsequential, with rates in probability samples of ED patients ranging from 16% (Soderstrom et al., 1997) to 22% (Cornwell et al., 1998
). A positive screen for either alcohol or other drugs has been found to be associated with a 40% higher rate of positivity for the other substance in selected ED samples (Rivara et al., 1989
; Buchfuhrer and Radecki, 1996
), and rates for drug use alone have been found to be lower than for drug use in combination with alcohol across all classes of drugs tested (Madan et al., 1999
). In this sample of ED patients drug users were usually also heavy drinkers.
A previous study from our group among injured patients in three EDs in Pachuca found an OR of 3.25 for any drug use and an OR of 2.88 for alcohol use disorders (Borges et al., 1998). Both estimates are comparable with the ones of the current report. A previous US study among Mexican Americans reported an OR for injury (compared with non-injury) of 1.66 for any drug use in the past year among ED patients (Cherpitel and Borges, 2001
). In addition, alcohol use and alcohol use disorders showed larger ORs than substance use and substance use disorders, when both variables were considered together.
Limitations
A major limitation is the use of self-reported alcohol and substance use data, and the retrospective nature of the CIDI questions. However, previous studies in the ED in Mexico have found that self-reported acute alcohol has good agreement with breath test (Cherpitel et al., 1992), and although there are no data in EDs in Mexico for concordance between self-reported substance use and biological specimens, studies among Mexican migrants in the US have shown good agreement (Vega et al., 1997
). Validity of the CIDI for AUDs and SUDs has been shown to be adequate in the international context, including Mexico (Vega et al., 2002
), but ED patients maybe more likely to deny the use of illicit substances (Hser et al., 1999
). If the latter happened in our study, our calculations of ORs for substance use would be underestimated. Further research on the validity of self-reported substance use and SUDs in the context of the ED is an important step for future research.
Generalizability of results
A single ED facility was used and although injury cases in our sample are representative of this facility, they may not represent the full spectrum of ED patients from Mexico City. Controls used for this comparison were sampled from the greater Mexico City area, and it is possible that residents from the catchments area served by this ED may report differences in alcohol and substance use than reported for the entire city. Since the M-NCS reported no differences in the 12-month prevalence of both AUDs and SUDs across the six regions of Mexico (Medina-Mora et al., 2003), it seems unlikely that there are differences across smaller areas in Mexico City alone.
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CONCLUSIONS |
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Large levels of comorbid AUDs and SUDs were reported, and AUDs showed a larger involvement with injury than SUDs.
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ACKNOWLEDGEMENTS |
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This study was supported by the Consejo Nacional de Ciencia y Tecnología (CONACyT) (39607-H) and a National Alcohol Research Centre grant AA 0559512 from the U.S. National Institute on Alcohol Abuse and Alcoholism. Data from the Emergency Department was collected under the World Health Organization (Geneva) and the National Institute of Psychiatry Ramon de la Fuente (4275P) (Mexico). Support for the Mexican National Comorbidity Survey (M-NCS) data collection came from The National Institute of Psychiatry Ramon de la Fuente (INPRFM-DIES 4280) and by the National Council on Science and Technology (CONACyT-G30544-H), with supplemental support from the Pan American Health Organization (PAHO).
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