Screening for and detection of depression, panic disorder, and PTSD in public-sector obstetric clinics

OBJECTIVE: This study assessed rates of detection and treatment of minor and major depressive disorder, panic disorder, and posttraumatic stress disorder among pregnant women receiving prenatal care at public-sector obstetric clinics. METHODS: Interviewers systematically screened 387 women attending prenatal visits. The screening process was initiated before each woman's examination. After the visit, patients were asked whether their clinician recognized a mood or anxiety disorder. Medical records were reviewed for documentation of psychiatric illness and treatment. RESULTS: Only 26 percent of patients who screened positive for a psychiatric illness were recognized as having a mood or anxiety disorder by their health care provider. Moreover, clinicians detected disorders among only 12 percent of patients who showed evidence of suicidal ideation. Women with panic disorder or a lifetime history of domestic violence were more likely to be identified as having a psychiatric illness by a health care provider at some point before or during pregnancy. All women who screened positive for panic disorder had received or were currently receiving mental health treatment outside the prenatal visit, whereas 26 percent of women who screened positive for major or minor depression had received or were currently receiving treatment outside the prenatal visit. CONCLUSIONS: Detection rates for depressive disorders in obstetric settings are lower than those for panic disorder and lower than those reported in other primary care settings. Consequently, a large proportion of pregnant women continue to suffer silently with depression throughout their pregnancy. Given that depressive disorders among perinatal women are highly prevalent and may have profound impact on infants and children, more work is needed to enhance detection and referral.     

Gender differences in prevalence,risk, and clinical correlates of alcoholism comorbidity in bipolar disorder

OBJECTIVE: The prevalence of lifetime alcohol abuse and/or dependence (alcoholism) in patients with bipolar disorder has been reported to be higher than in all other axis I psychiatric diagnoses. This study examined gender-specific relationships between alcoholism and bipolar illness, which have previously received little systematic study. METHOD: The prevalence of lifetime alcoholism in 267 outpatients enrolled in the Stanley Foundation Bipolar Network was evaluated by using the Structured Clinical Interview for DSM-IV. Alcoholism and its relationship to retrospectively assessed measures of the course of bipolar illness were evaluated by patient-rated and clinician-administered questionnaires. RESULTS: As in the general population, more men (49%, 57 of 116) than women with bipolar disorder (29%, 44 of 151) met the criteria for lifetime alcoholism. However, the risk of having alcoholism was greater for women with bipolar disorder (odds ratio=7.35) than for men with bipolar disorder (odds ratio=2.77), compared with the general population. Alcoholism was associated with a history of polysubstance use in women with bipolar disorder and with a family history of alcoholism in men with bipolar disorder. CONCLUSIONS: This study suggests that there are gender differences in the prevalence, risk, and clinical correlates of alcoholism in bipolar illness. Although this study is limited by the retrospective assessment of illness variables, the magnitude of these gender-specific differences is substantial and warrants further prospective study.     

Elevated risk of tobacco dependence among offspring of mothers who smoked during pregnancy: a 30-year prospective study

OBJECTIVE: The authors' goal was to investigate whether maternal smoking during pregnancy is associated with an increased risk of nicotine dependence among adult offspring. METHOD: Prospective data from two samples of offspring in the National Collaborative Perinatal Project, a long-term prospective investigation from pregnancy through adulthood, were combined (N=1,248). Maternal smoking during pregnancy was assessed during each prenatal visit. Offspring smoking behavior and lifetime risk of nicotine dependence were obtained by structured interview with the Diagnostic Interview Schedule; the mean age of the offspring at the time of interview was 29 years. RESULTS: Offspring whose mothers reported smoking a pack or more of cigarettes during their pregnancy were significantly more likely to meet DSM criteria for lifetime tobacco dependence than offspring of mothers who reported that they never smoked during pregnancy. The odds of progressing from smoking to nicotine dependence were almost twice as great for offspring whose mothers smoked heavily during pregnancy. These significant differences remained after adjustments for participants' gender and age and maternal socioeconomic status and age at pregnancy. Results were comparable for men and women. The findings were specific for tobacco dependence; odds of marijuana dependence were not significantly elevated among the offspring of tobacco smokers. CONCLUSIONS: Offspring of mothers who smoked a pack or more of cigarettes during pregnancy are at elevated risk of developing nicotine dependence but not marijuana dependence as adults. Maternal smoking during pregnancy is a risk factor for subsequent nicotine dependence among offspring.     

A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking

BACKGROUND: Prenatal alcohol exposure may be a risk factor for the development of alcohol problems in humans. METHODS: We use data beginning with interviews of women in prenatal care at midpregnancy to predict alcohol use and alcohol-related problems in their offspring now aged 21 years. Maternal drinking during pregnancy was assessed from November 4, 1974, through October 2, 1975, along with measures of maternal smoking, use of caffeine and other drugs, and demographic factors. Family history of alcohol problems was assessed from interviews with parents when offspring were 14 years of age and updated when offspring were 21 years of age. Measures of parental use of alcohol and other drugs and many aspects of the family environment were assessed at 7 different ages, prenatally through 21 years. Young adult offspring (age, 21 years [N = 433]) provided self-reports of drinking quantity and frequency and completed the Alcohol Dependence Scale as a measure of alcohol-related problems and dependence. RESULTS: Univariate, partial least squares, and regression analyses indicate that prenatal alcohol exposure is significantly associated with alcohol problems at 21 years of age. The relationship persists independent of the effects of family history of alcohol problems, nicotine exposure, other prenatal exposures, and postnatal environmental factors including parental use of other drugs. Prenatal nicotine exposure was not associated with alcohol problems by offspring at 21 years of age. CONCLUSIONS: Prenatal alcohol exposure is a risk factor for the development of drinking problems in humans. Potential mechanisms for the role of fetal exposure and the development of alcohol problems deserve study.     

Long-term stability of alcohol and other substance dependence diagnoses and habitual smoking: an evaluation after 5 years

CONTEXT: A major criterion to validate diagnoses is stability over time. OBJECTIVE: To examine the stability of several classification systems for lifetime diagnosis of alcohol dependence, to identify characteristics predicting stability of alcoholism, and to study stability of lifetime assessments of habitual smoking (1 pack per day for at least 6 months) and other drug dependence. DESIGN: Participants in the Collaborative Study on the Genetics of Alcoholism were interviewed using the Semi-Structured Assessment for the Genetics of Alcoholism and reevaluated 5 years later. Initial and follow-up interviews were available for 1728 individuals (641 index cases, 800 siblings, 287 controls) with lifetime diagnoses of alcohol dependence, other substance dependence (marijuana, cocaine, other stimulants, sedatives, opioids), or habitual smoking at first interview. The likelihood that an individual with a lifetime history of substance dependence or habitual smoking at the first interview retained this classification after 5 years was examined to assess stability of diagnosis. RESULTS: Stability of a lifetime diagnosis of alcohol dependence varied among the subject groups of index cases, siblings, and community-based controls. Alcohol dependence as defined by DSM-III-R criteria was highly stable in the index cases (90.5% women, 94.7% men) but much less stable in the community-based controls (27.5% women, 64.7% men). The most important characteristic associated with stability of diagnosis of alcohol dependence was severity, defined by the number of alcohol-related symptoms. Other DSM-III-R substance dependence disorders varied in the stability of diagnosis over a 5-year period. Lifetime history of habitual smoking was highly stable in all subject groups (96.0% overall). CONCLUSIONS: Stability of lifetime assessment of alcohol dependence varies depending on severity of illness. Severe cases of alcohol dependence are more likely to be stable, whereas general population cases of alcohol dependence are less likely to have stable diagnoses. The stability of diagnosis for other substance dependence varies from substance to substance.     

Depression and familial risk for substance dependence: a P300 study of young women

The present study evaluated the effects of depression and a family history of alcohol or substance dependence on P300 event-related potentials in young women aged 14 to 20 years. Of the 130 female subjects, 29 met DSM-III-R diagnostic criteria for a lifetime history of a Major Depressive Episode. Event-related electroencephalographic potentials were recorded from each subject while she performed a complex visual oddball task. Analyses indicated a decrement in P300 amplitude in the depressed group as compared to girls with no history of depression. No effects of family history of alcoholism or drug dependence were detected. Current source density analyses, utilizing a realistic head-shape boundary element model, indicated that the difference between the depressed and non-depressed groups was maximal in the right prefrontal region. These results provide further support for the notion that the cognitive difficulties associated with depression are subtle and best detected with sensitive neurophysiological indices, such as P300.     

Effects of major depression on remission and relapse of substance dependence

BACKGROUND: The effects of major depressive disorder (MDD) on the course of substance dependence may differ depending on the temporal relationship of depression to dependence. We investigated the effects of MDD on the outcome of substance dependence under 3 circumstances: (1) lifetime onset of MDD prior to lifetime onset of dependence onset, (2) current MDD occurring during a period of abstinence, and (3) current MDD during substance use that exceeded the expected effects of intoxication or withdrawal. METHODS: A sample of 250 inpatients with DSM-IV cocaine, heroin, and/or alcohol dependence were followed up at 6, 12, and 18 months. The Psychiatric Research Interview for Substance and Mental Disorders (PRISM) was used to make DSM-IV diagnoses. Using Cox proportional hazards models, stable remissions (those lasting at least 26 weeks) from DSM-IV cocaine, heroin, and/or alcohol dependence and from use were studied, as well as subsequent relapses of dependence and use. RESULTS: Patients with current substance-induced MDD were less likely to remit from dependence (adjusted hazards ratio, 0.11) than patients with no baseline MDD. A history of MDD prior to lifetime onset of substance dependence also reduced the likelihood of remission relative to the absence of such a history (adjusted hazard ratio, 0.49). Major depressive disorder during sustained abstinence predicted dependence relapse (adjusted hazards ratio, 3.07) and substance use after hospital discharge compared with those without abstinence MDD (adjusted hazards ratio, 1.45). CONCLUSION: The timing of depressive episodes relative to substance dependence served as an important factor in the remission and relapse of substance dependence and substance use.     

Sex differences in shoplifting: results from a national sample

ABSTRACT: This study presents the sex differences in sociodemographics and in psychiatric correlates of shoplifting in the United States. Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of US adults. Shoplifting was associated with numerous psychiatric and addictive disorders with significant sex effects. Women with a lifetime history of shoplifting were significantly more likely than men with a lifetime history of shoplifting to have a lifetime diagnosis of alcohol abuse or dependence, nicotine dependence, cannabis, amphetamine, cocaine, or inhalant use disorder, and antisocial personality disorder, whereas men were significantly more likely than women to have a lifetime diagnosis of generalized anxiety disorder. The findings suggest that shoplifting could be better understood as a behavioral manifestation of a broader impaired impulse control spectrum in women. Shoplifting could be more a part of the externalizing spectrum disorders rather than the internalizing spectrum disorders in women compared to men.     

From one beer with friends to alcohol dependence: a synthesis about our knowledge of this path

Review paper about prospective studies concerning the natural history of alcoholism. Emphasizing Vaillant and the impact of his contribution to the evolution of the concepts of harmful use and dependence, as well as its most important therapeutic implications. The fact that the abstinence rates, in the treatment of a severe dependence, almost remaining the same in the last twenty-five years is highlighted.     

Psychiatric comorbidity and suicidality among intravenous drug users.

BACKGROUND: Prevalence of lifetime psychiatric comorbidity and history of attempted suicide among intravenous drug users was investigated. METHOD: One thousand sixty-two relatives of hospitalized alcoholics, felons, and control subjects were administered a structured interview that gathered data on lifetime psychiatric symptoms and psychoactive drug use. Psychiatric diagnoses were based on interview information, medical records, and family history data. Comparisons were made between 411 subjects who used no illicit drugs, 329 cannabis users, 230 subjects who had used psychoactive drugs other than cannabis more than five times but had never injected drugs, and 92 intravenous drug users. RESULTS: Any history of injecting drugs increased the odds of being diagnosed with antisocial personality disorder by a factor of 21.01, alcoholism by 4.42, and unipolar depression by 3.02. A diagnosis of antisocial personality disorder increased the odds of having injected drugs by a factor of 27.19, while diagnoses of alcoholism or unipolar depression conveyed odds for injecting drugs of 4.62 and 3.70, respectively. Intravenous drug use was associated with an 8.27-fold increase in odds for a suicide attempt compared with no drug use. CONCLUSION: Rates of alcoholism, depression, and antisocial personality disorder, but not other psychiatric disorders (other than drug dependence), are significantly elevated in intravenous drug users. Moreover, among drug users, the decision to inject is differentially made by those with antisocial personality disorder. A history of suicide attempt is common among intravenous drug users, but injecting appears to convey little additional risk above substantial but non-intravenous drug use.     

Should caffeine abuse, dependence, or withdrawal be added to DSM-IV and ICD-10?

OBJECTIVE: The authors reviewed basic science and clinical data on caffeine abuse, dependence, and withdrawal in order to make a conclusion about whether these disorders exist and should be included in DSM-IV and ICD-10. METHOD: Studies were located through computerized searches, reference sections of published articles, and written requests. RESULTS: The studies show that abstinence from caffeine induces a withdrawal syndrome of headache, fatigue, and drowsiness which begins within 12-24 hours and lasts about 1 week. The syndrome can be severe and appears to be one reason for continued use of coffee. The prevalence of this caffeine withdrawal syndrome is unknown. Use of caffeine may aggravate some common behavioral and medical disorders. In double-blind tests, a subset of coffee and soda drinkers reliably self-administered caffeinated beverages in preference to uncaffeinated beverages. Clinical indicators of dependence, such as difficulty stopping use of caffeine and use despite harm, have not been documented. CONCLUSIONS: Caffeine withdrawal but not caffeine abuse or dependence should be included as a diagnosis in DSM-IV and ICD-10. Future research should focus on whether some caffeine users exhibit clinical indicators of drug dependence.     

Maternal smoking during pregnancy and psychopathology in offspring followed to adulthood.

OBJECTIVE: To extend findings from several independent reports of an association between maternal smoking during pregnancy and attention-deficit hyperactivity disorder, conduct disorder, and substance abuse in the offspring. METHOD: This is a 10-year longitudinal study of offspring assessed at 3 points in time into adulthood. Fifty offspring of mothers who reported smoking at least 10 cigarettes almost daily during pregnancy and 97 offspring of mothers who reported never smoking during pregnancy were studied. Psychiatric diagnosis in offspring was assessed blind to parental diagnosis. RESULTS: There was a greater than 4-fold increased risk of prepubertal-onset conduct disorder in boys and a greater than 5-fold increased risk of adolescent-onset drug dependence in girls whose mothers smoked 10 or more cigarettes almost daily during pregnancy. These findings could not be explained by maternal substance abuse during pregnancy, parental psychiatric diagnosis, family risk factors, prenatal and early developmental history of offspring, postnatal maternal smoking, or smoking in the offspring. CONCLUSIONS: Maternal smoking during pregnancy may have a long-term effect on specific psychopathology in offspring. The underlying pathophysiology of nicotine on the fetus requires study. The findings suggest the importance of programs aimed at smoking prevention and cessation in women during pregnancy.     

Pre-eclampsia and nasal CPAP: part 2. Hypertension during pregnancy, chronic snoring, and early nasal CPAP intervention

OBJECTIVES: To evaluate the potential benefit of nasal continuous positive airway pressure (CPAP) administration in pregnant women recognized to have hypertension early in pregnancy. METHODS: This is a randomized study comparing the addition of nasal CPAP treatment to standard prenatal care to standard prenatal care alone in hypertensive women treated with alpha-methyl dopa during early pregnancy. Pregnant women with hypertension were recruited by their obstetricians and completed baseline sleep questionnaires and visual analogue scales on snoring and sleepiness. Subjects were then randomized to receive either CPAP with standard prenatal care (treatment group) or standard prenatal care alone (control group) with routine obstetric follow-up. Nocturnal polysomnography was performed in all patients randomized to the treatment group for initial CPAP titration. Periodic assessment of blood pressure control and CPAP compliance was performed by the same specialist at each scheduled follow-up visit. RESULTS: In the control group (n=9), a progressive rise in blood pressure with a corresponding increase in alpha-methyl dopa doses was observed, beginning at the sixth month of pregnancy. There was also an increase in the number of non-scheduled post-natal visits during the first postpartum month. Pre-eclampsia occurred in one subject; the remaining eight patients had normal pregnancies and infant deliveries. In the treatment group (n=7), blood pressure was noted to decrease significantly as compared to the control group with associated decreases in doses of antihypertensive medications at six months of gestation. All treated patients experienced uncomplicated pregnancies and delivered infants with higher APGAR scores at one minute post-delivery compared to those of controls. CONCLUSION: In pregnant women with hypertension and chronic snoring, nasal CPAP use during the first eight weeks of pregnancy combined with standard prenatal care is associated with better blood pressure control and improved pregnancy outcomes.     

Altered NMDA glutamate receptor antagonist response in individuals with a family vulnerability to alcoholism

OBJECTIVE: A family history of alcoholism is a risk factor for the development of ethanol dependence. Ethanol is an antagonist of the N-methyl-d-aspartate (NMDA) glutamate receptor, and alterations in NMDA receptor function are thought to be involved in ethanol abuse and dependence. The purpose of this study was to determine in healthy individuals with no ethanol dependence whether response to the NMDA receptor antagonist ketamine would differentiate those with a family history of ethanol dependence from those without such a family history. METHOD: Healthy subjects between the ages of 21 and 30 received 40-minute intravenous infusions of saline, low-dose ketamine (0.1 mg/kg), and high-dose ketamine (0.5 mg/kg) on three separate test days in a randomized order under double-blind conditions. The healthy individuals with at least one first-degree relative and another first- or second-degree relative with ethanol dependence (N=16) were compared with those who had no family history of ethanol dependence in any first- or second-degree relative (N=29). Outcome measures included the Brief Psychiatric Rating Scale, Clinician-Administered Dissociative States Scale, verbal fluency, Hopkins Verbal Learning Test, a biphasic alcohol effects scale, visual analog scales of mood states, and ketamine levels. RESULTS: During ketamine infusion, individuals with a family history of ethanol dependence showed an attenuated response in terms of perceptual alterations and dysphoric mood relative to those without such a family history. CONCLUSIONS: These data suggest that alterations in NMDA receptor function may contribute to subjective response to ethanol and therefore also to the risk of developing alcoholism.     

The social complications of chronic alcohol abuse: relative influence of family history and severity of alcohol dependence

Alcoholics with a family history of the disease are said to present more severe consequences than alcoholics without such a history. This study examined the frequency distribution of severe alcohol dependence and police arrests for public drunkenness across samples of alcoholics with (n = 77) and without (n = 37) a family history of alcoholism. Both the percentage of subjects presenting severe dependence and the history of police arrests were greater in the positive family history group, but these differences did not reach conventional levels of statistical significance. However, results of logistic regression analyses demonstrate that male sex, younger age and, above all, severity of alcohol dependence, are better correlates of the occurrence of police arrests than is the subject's family history of alcoholism. The picture presented by this sample of outpatient alcoholics appears to qualify some currently held assumptions of the influence of family history on the phenomenology of alcoholism.     

Sex-specific genetic influences on the comorbidity of alcoholism and major depression in a population-based sample of US twins

BACKGROUND: Alcoholism and depression frequently co-occur, but the origins of this comorbidity remain uncertain. Most previous family, twin, and adoption studies of these disorders have used cases ascertained through treatment settings, who may differ from cases in epidemiological samples. We studied the importance of genetic influences on risk for lifetime comorbidity of major depression and alcoholism by means of a population-based twin sample. METHODS: Lifetime major depression (MD), alcohol abuse, and alcohol dependence were assessed by structured interview for both members of 3755 twin pairs from the Mid-Atlantic Twin Registry. Pair resemblance was analyzed by means of structural equation models. RESULTS: Individuals with MD were at significantly increased risk for alcohol dependence and for a combined diagnosis of alcohol abuse and/or dependence. History of MD in a twin significantly increased the risk of cotwin alcohol dependence and alcohol abuse and/or dependence among identical male pairs and for alcohol abuse and/or dependence in identical female pairs, but not among male or female fraternal pairs. Results of structural modeling indicate that comorbidity occurs because the genetic and specific environmental sources of liability to MD overlap with those underlying alcohol dependence and alcohol abuse and/or dependence. This overlap was significant only within sex, not across sexes. CONCLUSIONS: In this population-based twin sample, the familial transmission of MD and alcohol dependence was largely disorder specific. Comorbidity appears to be due to sex-specific genetic and environmental risk factors. The factors underlying depression in women do not appear to arise from the same factors underlying alcoholism in men.     

Implications of family history of alcoholism, antisocial personality, and sex differences in alcohol dependence

In this study of 210 male and female alcoholic inpatients, significant associations were found 1) between antisocial personality diagnosis and early onset of all stages in alcohol dependence; 2) between bilineal family history of alcoholism and greater frequency of the consequences of impaired control, withdrawal symptoms, and the pathologic symptoms associated with chronic alcoholism; and 3) between being female and older at onset of the initial, but not final, stages of alcoholism and having more symptoms associated with chronic alcohol use. Antisocial personality, type of family history, and sex of the proband were not interactive but contributed separate additive effects.     

Use of health services by men with and without antisocial personality disorder who are alcohol dependent

In a sample of 104 medically stable male veterans with alcohol dependence, rates of health service utilization were compared for 48 patients with a primary diagnosis of antisocial personality disorder and 56 patients without this diagnosis. Patients were diagnosed using DSM-IV lifetime criteria; previous utilization of health services was based on self-reports. Although a similar proportion of both groups reported previous service use, patients with antisocial personality disorder reported using more substance abuse treatment services than those with a primary diagnosis of alcohol dependence. Between-group multiple regression analysis showed that an earlier age at onset of alcoholism and a history of a comorbid substance-induced mental disorder best predicted higher rates of use of substance abuse treatment.     

Tobacco smoking among people living with a psychotic illness: The second Australian survey of psychosis

Objective: The aims of this study were to (a) describe patterns of tobacco smoking among Australians living with a psychotic illness and (b) explore the association between smoking and measures of psychopathology, psychiatric history, psychosocial functioning, physical health, substance use and demographic characteristics. Methods: Data were from 1812 participants in the 2010 Australian Survey of High Impact Psychosis. Participants were aged 18-64 years and resided in seven mental health catchment sites across five states of Australia. Bivariate statistics were used to compare smokers with non-smokers on the measures of interest, and to compare ICD-10 diagnostic categories on measures of smoking prevalence, nicotine addiction and quitting history. Multivariate logistic regression was used to test whether (a) demographics and psychiatric history were associated with having ever smoked and (b) whether symptoms and psychosocial functioning were independently associated with current smoking, after controlling for demographics, psychiatric history and substance use. Results: The prevalence of current tobacco smoking was 66.6% (72% of men and 59% of women); lifetime prevalence was 81%. In univariate analyses, individuals with a diagnosis of schizophrenia or schizoaffective disorder were most likely to be smoking tobacco (70%) and were more nicotine dependent. Smokers reported worse perceived physical health, lower body mass index and waist circumference, and more lifetime medical conditions. A younger age of illness onset, male gender and low education were associated with having ever smoked. Associations with current smoking included low education, male gender, no formal employment, worse negative symptoms, higher daily caffeine consumption, and alcohol dependence and substance abuse/dependence. Conclusions: The prevalence of tobacco smoking is high amongst people with a psychotic disorder, and is associated with adverse mental health symptoms as well as high rates of other substance use, poorer subjective physical health, and a higher risk of the many known health consequences of smoking.     

Cross-sectional volumetric analysis of brain atrophy in alcohol dependence: effects of drinking history and comorbid substance use disorder

OBJECTIVE: The authors assessed whether individual differences in drinking history as well as lifetime incidence of comorbid cocaine or marijuana use disorder underlie differential patterns of brain atrophy in subjects with alcohol dependence. METHOD: Segmented magnetic resonance images were used to compare whole brain cerebral gray matter and white matter in 134 male subjects age 30-50 with alcohol dependence, either alone or with comorbid cocaine or marijuana use disorder. RESULTS: Across all subjects, drinking history variables correlated negatively with both gray matter and white matter after age was controlled. Alcohol-dependent subjects with no comorbid substance use disorder (N=51) showed a steeper negative correlation between age and the gray matter/white matter ratio than did alcohol-dependent subjects with a comorbid lifetime cocaine use disorder diagnosis (N=50). Alcohol-dependent subjects with comorbid cocaine use disorder tended to have a steeper negative correlation between age and white matter (adjusted for intracranial volume) than did alcohol-dependent subjects with no comorbid substance use disorder. After age and the greater estimated cumulative alcohol consumption of alcohol-dependent subjects with comorbid cocaine use disorder were controlled in a multiple regression analysis, however, comorbid cocaine use disorder did not account for any independent variance in any volumetric measure. CONCLUSIONS: Brain atrophy among subjects with alcohol dependence reflects individual differences in exposure to alcohol, and the data provide mixed evidence that comorbid cocaine use disorder may exacerbate white matter atrophy in alcoholism.