Comorbid trajectories of substance use as predictors of Antisocial Personality Disorder, Major Depressive Episode, and Generalized Anxiety Disorder

Highlights

• We examined comorbid trajectories of substance use from adolescence to adulthood.

• 4 trajectory groups of comorbid substance use and one non-use group were extracted.

• The 4 groups were more likely than non-users to have psychiatric disorders at age 37.

• The most severe substance-using group had the highest risk for psychiatric disorders.

• Treatment programs for community adults may need to address comorbid conditions.

Abstract

Objective

To determine longitudinal associations between patterns of comorbid cigarette, alcohol, and marijuana use and Antisocial Personality Disorder (ASPD), Major Depressive Episode (MDE), and Generalized Anxiety Disorder (GAD) in adulthood.

Method

A random community-based sample [$\bar{\mathrm{X}}$ age = 36.6 (SD = 2.8)] from the Children and Adults in the Community Study, an on-going investigation of substance use and psychiatric disorders. Data were collected at six time waves. Conjoint trajectories of cigarette, alcohol, and marijuana use spanning adolescence to adulthood were determined; multivariable logistic regression analyses assessed associations between trajectory group membership and having ASPD, MDE, or GAD in adulthood.

Results

Five conjoint trajectory groups were obtained: HHH (chronic cigarette, alcohol, and marijuana use), DDD (delayed/late-starting cigarette, alcohol, and marijuana use), LML (low/no smoking, moderate alcohol use, occasional marijuana use), HMN (chronic smoking, moderate alcohol use, no marijuana use), and NON (occasional alcohol use only). Compared with members of the NON group, those in the HHH group had significantly greater odds for having ASPD (Adjusted Odds Ratio [AOR] = 28.52, 95% Confidence Interval [CI] = 9.44–86.17), MDE (AOR = 2.67, 95% CI = 1.14–6.26), and GAD (AOR = 6.39, 95% CI = 2.62–15.56). Members of the DDD, LML, and HMN groups had weaker and less consistent associations with the three psychiatric outcomes.

Conclusions

In a large, community-based sample, long-term concurrent use of more than one substance was associated with both externalizing and internalizing psychiatric disorders in adulthood. Prevention and treatment programs might target individuals in the community and general clinical populations with comorbid substance use, even if they haven't been identified as having a substance use disorder.

Introduction

Substance use is often comorbid with psychopathology (Agrawal et al., 2012, Chen et al., 2002, Degenhardt and Hall, 2003, Degenhardt et al., 2001, Hämäläinen et al., 2001, Jackson et al., 2008). According to the National Survey on Drug Use and Health, the use of individual substances—such as cigarettes, alcohol, or marijuana—among persons aged 18 years or older was associated with about twice the odds of having reported a Major Depressive Episode (MDE) (SAMHSA, 2014). However, while the concurrent use of more than one substance (e.g., tobacco and alcohol) is common (Degenhardt and Hall, 2003, Jackson et al., 2008, Witkiewitz et al., 2012), there has been less empiric research on associations between patterns of comorbid substance use and psychopathology. Comorbid substance use may stem from both genetic and psychosocial factors (Agrawal et al., 2012, Palmer et al., 2009, Young et al., 2006). Increasing evidence points to a genetic overlap in the propensity to use tobacco, alcohol, and marijuana (Young et al., 2006, Sartor et al., 2010), and factors such as behavioral undercontrol, poor familial relationships, affiliation with deviant peers, and drug accessibility may also predispose the individual to heterogeneous substance use (Agrawal et al., 2012, Brook et al., 2012a, Van Ryzin et al., 2012). Therefore, a better understanding of distinct patterns of comorbid substance use may be more practically relevant to prevention and treatment programming than focusing on the use of an individual substance, e.g., marijuana.

In addition, most studies on substance use and psychopathology have examined individuals already in treatment for substance use disorders (SUDs). These investigations have shown that individual use of cigarettes, alcohol, or marijuana is associated with conditions such as Antisocial Personality Disorder (ASPD), Major Depressive Episode (MDE), and Generalized Anxiety Disorder (GAD) (Chen et al., 2002, Kedzior and Laeber, 2014). However, such studies do not take into account the large number of adults in the community who have engaged in long-term substance use that does not meet the threshold of a disorder. More work in this area may illuminate the potential value of addressing comorbid substance use in community-based populations and/or clinical populations of individuals who have not yet been identified as having SUDs.

Another important gap in the literature is that most investigations on associations between substance use and psychopathology have employed cross-sectional designs and/or measured substance use during a narrowly circumscribed period—typically adolescence and/or young adulthood. These approaches, while valuable, do not address the extent to which persistent substance use may affect individuals' lives over time or its impact during adulthood. Substance use may be associated with later psychopathology due to shared underlying psychosocial and genetic factors (Malone, Taylor, Marmorstein, McGue, & Iacono, 2004) or due to the adverse physiological and psychological effects of the substance(s) on the individual, such as dysregulated stress reactivity (Lovallo, 2006). A greater understanding of long-term comorbid substance use and its association with later psychopathology among a community sample will be valuable to the design and improvement of treatment programs for such comorbidity.

The present study extends prior research by addressing the preceding voids in the research literature. In particular, we examine patterns of the comorbid use of three substances of abuse (tobacco, alcohol, and marijuana) among a community-based sample across a span of 23 years. Further, we determine associations between these patterns and psychopathology (ASPD, MDE, and GAD) in adulthood. Our hypotheses are based on the few studies on comorbid tobacco, alcohol, and marijuana use and on trajectory analyses of the use of one or two of these substances (Brook et al., 2012b, Caldeira et al., 2012). Specifically, we hypothesized approximately seven trajectory groups of substance use, consisting of: 1) chronic, heavy users of all three substances (tobacco, alcohol and marijuana); 2) a delayed/late-starting group, in which members used all three substances; 3) an alcohol and marijuana use only group; 4) a cigarette and alcohol use group; 5) a cigarette and marijuana use group; 6) a declining or “maturing out” group that used cigarettes, alcohol and/or marijuana at rates that started to decline in the late 20s; and 7) a group that used no substances at all or engaged in occasional alcohol use only. We hypothesized that, compared with membership in the low/non-use trajectory group, membership in each of the trajectory groups of comorbid substance use would be associated with ASPD, MDE, and GAD in adulthood (H1). Additionally, we expected that membership in the heaviest use groups would be more highly related to ASPD, MDE, and GAD than membership in the lower use groups (H2). Finally, we hypothesized that trajectory groups in which members used marijuana (an illicit substance) would be more highly associated with ASPD than membership in trajectory groups that used cigarettes and/or alcohol only (H3).