NIH Public Access
Author Manuscript
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
NIH-PA Author Manuscript
Published in final edited form as:
J Youth Adolesc. 2010 February ; 39(2): 177–188. doi:10.1007/s10964-008-9385-5.
The Relationship Between Anxiety Disorders and Substance Use
Among Adolescents in the Community: Specificity and Gender
Differences
Ping Wu1,2,3, Renee D. Goodwin1, Cordelia Fuller3, Xinhua Liu1, Jonathan S. Comer2,3,
Patricia Cohen1,2,3, and Christina W. Hoven1,2,3
1 Mailman School of Public Health, Columbia University, New York, NY, USA
2
College of Physicians and Surgeons, Columbia University, New York, NY, USA
3
Division of Child Psychiatry, New York State Psychiatric Institute, 1051 Riverside Drive, Unit 43,
New York, NY 10032, USA, e-mail: wup@childpsych.columbia.edu
NIH-PA Author Manuscript
Abstract
Using a sample of 781 adolescents (ages 13–17, 52.8% male) from a community survey, this study
examined gender differences in the co-occurrence of specific anxiety disorders with substance use
in adolescents. The associations between anxiety disorders and substance use differed according to
the particular anxiety disorders and forms of substance use being examined, as well as by gender.
Social phobia was associated with cigarette smoking among boys only. For girls, social phobia
appeared to be negatively associated with drug use. For the other anxiety disorders, the associations
with substance use tended to be stronger among girls. These findings highlight the need to improve
clinical recognition of the anxiety disorders and to improve treatment access for afflicted adolescents.
Future studies based on longitudinal data could further elucidate the relationships among anxiety
disorders, gender, and substance use.
Keywords
Anxiety disorders; Substance use; Comorbidity; Adolescence; Gender
NIH-PA Author Manuscript
Introduction
Substance use disorders comorbid with anxiety disorders are common in the population (Book
and Randall 2002; Christie et al. 1988; Compton et al. 2007; Grant et al. 2004a; Hall and Farrell
1997; Hasin et al. 2007; Kessler et al. 1996), and tend to be more difficult to treat than substance
use disorders alone (Book and Randall 2002; Grothues et al. 2008; Helzer and Pryzbeck
1988; Zimmermann et al. 2004). Adolescence tends to be the time of life during which
substance use and abuse begin to develop (Young et al. 2002). Anxiety disorders, similarly,
typically have their onsets during childhood or adolescence (Kessler et al. 2005). Thus, in
seeking to better understand the nature of comorbidities between anxiety and substance use
disorders, it is crucial to examine patterns of the co-occurrence of anxiety disorders with
substance use and abuse, not only among adults, but also among adolescents.
Correspondence to: Ping Wu.
Wu et al.
Page 2
NIH-PA Author Manuscript
Studies examining anxiety and substance use disorders among community-dwelling adults
generally find the two types of disorders to be positively associated (Christie et al. 1988;
Compton et al. 2007; Eisen and Rasmussen 1989; Falk et al. 2008; Grant et al. 2004a; Kolada
et al. 1994; Kushner et al. 1999; Suzuki et al. 2002) (Johnson et al. 2000). There have been
fewer community studies examining the associations between anxiety disorders and substance
use and abuse among adolescents (Brook et al. 1998; Kandel et al. 1997; Rohde et al. 1996).
With regard to gender, findings have been highly inconsistent, both among adult studies
(Alonso et al. 2004; Bott et al. 2005; Burns and Teesson, 2002; Grant et al. 2004a; Gratzer et
al. 2004; Kessler et al. 1997) and among studies of adolescents (Kandel et al. 1997; Rohde et
al. 1996; Sung et al. 2004), as to whether associations between anxiety disorders and substance
use and abuse differ substantially between males and females. Given these inconsistencies, the
current study examines three categories of adolescent substance use (i.e., frequent smoking,
frequent/heavy drinking, and illicit drug use) in relation to each of six anxiety disorders (i.e.,
social phobia, agoraphobia, overanxious disorder/generalized anxiety disorder (OAD/GAD),
separation anxiety, and obsessive-compulsive disorder (OCD)), and focuses on gender
differences in the patterns of these relationships.
Anxiety Disorders in Relation to Substance Abuse Among Adults
NIH-PA Author Manuscript
Studies of adults have found that anxiety disorders in general tend to be positively related to
abuse of, and dependence on, both alcohol (Book and Randall 2002; Eisen and Rasmussen
1989; Falk et al. 2008; Kolada et al. 1994; Kushner et al. 1990; Merikangas et al. 1998; Suzuki
et al. 2002) and illicit drugs (Agrawal et al. 2007; Keyes et al. 2008). With regard to tobacco
use, however, findings have been more variable. A nationally representative community study
of adults in the United States found that nicotine dependence was positively associated with a
wide range of psychiatric disorders, including agoraphobia, social phobia, specific phobia,
generalized anxiety disorder, and OCD (Grant et al. 2004a). With regard to OCD, some clinical
studies have concluded that patients with this disorder appear to be less likely to smoke
compared to the general population (Bejerot and Humble 1999; Himle et al. 1988). However,
one community study done in northern Germany found OCD to be positively associated with
both nicotine and alcohol dependence among women (Grabe et al. 2001). In a community study
conducted in New York State (Johnson et al. 2000) heavy smoking among young adults was
found to be associated with generalized anxiety disorder but not with agoraphobia or social
phobia. With regard to gender, some adult community studies have found that associations
between the two types of disorders tend to be stronger among women than men (Burns and
Teesson 2002; Gratzer et al. 2004; Kessler et al. 1997). Other studies of adults, however, have
concluded that these associations do not differ by gender (Alonso et al. 2004; Bott et al.
2005; Grant et al. 2004a).
NIH-PA Author Manuscript
Anxiety Disorders in Relation to Substance Use Among Adolescents
Previous studies examining the relationship between anxiety and substance use in children and
adolescents have produced inconsistent, and often unclear, results. One cross-sectional study
of adolescents found anxiety disorders to be positively related to the frequent use of tobacco,
but not to the use of either alcohol or illicit drugs (Kandel et al. 1997). In a longitudinal study
of youth, anxiety was not found to be significantly related to any of the types of substance use
assessed (Brook et al. 1998). These studies did not distinguish among the various anxiety
disorders, instead employing only a single, general anxiety variable in their analyses. One study
of adolescents from the Great Smoky Mountains region of the United States did examine two
different childhood anxiety disorders separately in relation to alcohol use, and found that
adolescents with a history of one of the disorders (generalized anxiety disorder) were
significantly more likely to be alcohol users, whereas a history of the other anxiety disorder
(separation anxiety) appeared to indicate a decreased risk of alcohol use (Kaplow et al.
2001). This study was, however, unable to compare these relationships across different
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 3
NIH-PA Author Manuscript
substances, as only alcohol use was examined. With regard to the role of gender, some previous
studies have found anxiety to be significantly associated with alcohol abuse (Rohde et al.
1996), or with substance abuse in general (Sung et al. 2004), among girls but not among boys.
Kandel et al. (1997) on the other hand, found that anxiety was more strongly related to frequent
smoking among boys than among girls (Kandel et al. 1997). The inconsistencies among these
findings call for further research to be done in this area.
The Current Study
This study addresses three main questions regarding the relationship between anxiety and
substance use, and the role of gender in that relationship. First, we examine the relationships
of specific anxiety disorders (social phobia, agoraphobia, OAD/GAD, separation anxiety, and
OCD) with substance use behaviors (i.e., frequent smoking, frequent/heavy drinking, or illicit
drug use) among adolescents in the community. Second, we examine gender differences in
patterns of the co-occurrence of anxiety disorders and substance use among these adolescents.
Third, we assess gender differences, both in the relationship between comorbid anxiety/
depression and substance use, and in the relationship between anxiety comorbid with disruptive
disorders, and substance use.
NIH-PA Author Manuscript
Researchers who have examined comorbidity among psychiatric disorders have concluded that
it is the norm rather than the exception (Grant et al. 2004b; Kessler et al. 1996; Regier et al.
1990). Because depression has been found to be associated both with anxiety (Angst et al.
2002; Hasin et al. 2005; Kessler et al. 1996; Lepine et al. 1993; Wittchen et al. 1991) and with
substance use (Armstrong and Costello 2002; Breslau et al. 1993b; Breslau et al. 1998; Grant
et al. 2004a; Hasin et al. 2005; Kessler et al. 1996; Regier et al. 1990; Wu et al. 2006), we
recognized that any associations we might find between anxiety and substance use could be
due to their mutual relationship with depression. Our study was, therefore, designed to take
depression into account in the analyses. Disruptive disorders also are known to be highly related
to substance use/abuse (Armstrong and Costello 2002; Compton et al. 2007; Costello et al.
1999; Ronald C. Kessler et al. 1996). Therefore, this study also examines the patterns of
substance use of adolescents having anxiety disorders only, in comparison with those of
adolescents having both anxiety and disruptive disorders. Some important demographic and
family factors, such as age, gender, ethnicity, and family structure, as well parental drug/alcohol
problems, have also been shown to be associated with both anxiety and substance use/abuse
(Armstrong and Costello 2002; Costello et al. 1999; Wu et al. 2006). These factors are also
controlled for in all of our analyses.
Methods
NIH-PA Author Manuscript
Sample
Data are from two surveys done in the United States: The NIMH Methods for the Epidemiology
of Child and Adolescent Mental Disorders (MECA) Study (Lahey et al. 1996) and the
Westchester Study (Kovalenko et al. 2001). The full sample of 1,458 children and adolescents
(ages 9–17) was randomly selected from four geographic areas: (1) Hamden, East Haven and
West Haven, Connecticut (N = 314); (2) DeKalb, Rockdale, and Henry Counties, Georgia (N
= 299); (3) Westchester County, New York (N = 360 from the MECA study and N = 173 from
WS); and (4) San Juan, Puerto Rico (N = 312). The overall compliance rate of this combined
community sample was 85% (MECA Study 84% and Westchester Study community sample
94%). The study was conducted in 1992. The study protocol was reviewed and approved by
the Institutional Review Board of the New York State Psychiatric Institute. Detailed
information on the study is available elsewhere (Kovalenko et al. 2001; Lahey et al. 1996). A
subsample of these subjects—the adolescents, ages 13–17 (N = 781)—is used in this study.
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 4
NIH-PA Author Manuscript
The socio-demographic and family characteristics of the sample are presented for the whole
sample, and by gender, in Table 1. Forty-seven percent of the sample were girls, 49% White,
17% African American, and 27% Hispanic. The mean age was 15.
Measures
Trained interviewers interviewed one child and one parent/guardian in each household
regarding childhood psychopathology as measured by Version 2.3 of the Diagnostic Interview
Schedule for Children (DISC), which assesses psychiatric symptoms and diagnoses in children
and adolescents according to DSM-III-R criteria (Shaffer et al. 1996). Mental health service
utilization and a wide array of risk factors were also assessed (Goodman et al. 1998). Written
consent was obtained from both the parent/guardian and the child prior to the interview.
Interview length was ~3 h (Lahey et al. 1996).
Use of Alcohol, Cigarettes and Other Drugs
NIH-PA Author Manuscript
Information about each adolescent’s lifetime and past year use of alcohol, cigarettes and other
drugs, as well as frequency of use, was obtained from both the parent and the youth. If either
the parent or the child reported use of a substance by the child, the child was considered to be
a user. For the purposes of our analyses, binary substance use variables were created using the
following criteria: Adolescents who had smoked at least one cigarette per day in the last 6
months were classified as frequent smokers. Those who, over the past 6 months, had had a
drink at least once a week, or had been drunk at least once, were classified as having frequent
or heavy drinking. Adolescents who had, in the past year, used any illicit drug (such as
marijuana, cocaine, heroin, etc.), or had used psychotropic prescription drugs non-medically,
were classified as having illicit drug use. The cut-off values for these three substance use
variables were selected in order to allow us sufficient statistical power for detecting
associations with possible predictors. Our sample was one of community-dwelling adolescents,
and, as expected, did not contain many cases of individuals with full-blown substance
dependence.
Measures of Anxiety Disorders and Other Mental Disorders
NIH-PA Author Manuscript
Youth psychopathology in the 6 months prior to the interview was assessed using the DISC.
The validity and reliability of its measures have been reported elsewhere (Schwab-Stone et al.
1996; Shaffer et al. 1996). A diagnostic criterion was considered positive if reported by either
the parent or the child. A child was considered positive on any disorder when (1) DSM-III-R
criteria for that disorder were met, and (2) there was an indication of diagnosis-specific
impairment (Shaffer et al. 1996). Anxiety disorders included in this study are social phobia,
agoraphobia, OAD/GAD (overanxious disorder or generalized anxiety disorder), separation
anxiety, and obsessive-compulsive disorder (OCD). These various anxiety disorders are not
mutually exclusive. We also examined the presence of any anxiety disorder, as well as the
number of anxiety disorders, in relation to substance use. The depressive disorders assessed
include major depression and dysthymia. The disruptive disorders include attention deficit
hyperactivity disorder, conduct disorder, and oppositional defiant disorder.
Demographics and Family Factors
Youth demographic information includes gender, age, and ethnicity. Youth were divided into
four ethnic groups: non-Hispanic White, African-American, Hispanic, and Other. A dummycoded variable, White (non-Hispanic Whites), was created for logistic regression analyses.
Information about public assistance and family structure (living with both biological parents
vs. others) was obtained from parent interviews. The variable “parental drug/alcohol problems”
was coded “yes” if it was reported that either of the adolescent’s biological parents had stayed
overnight or longer, in a hospital or treatment facility, because of a drug or alcohol problem.
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 5
Analysis
NIH-PA Author Manuscript
Univariate analyses were conducted first, to describe the characteristics of the sample, in total
and by gender. Then, logistic regression analyses predicting substance use (i.e., frequent
smoking, frequent/heavy drinking, or drug use), with the anxiety disorders as the independent
variables, were conducted separately for boys and girls in two steps: In step 1 (Model 1), each
of the anxiety disorders was entered into the model, with demographic and family factors
controlled for; in step 2 (Model 2), depression (i.e., major depressive disorder or dysthymia)
was added to the equation to test whether the associations between the anxiety disorders and
substance use would still hold. Using gender specific logistic analyses, we obtained covariateadjusted odds ratios (AORs) for the associations between the anxiety and the substance use
variables, for boys and girls. Wald tests were then used to test for gender differences in the
AORs.
Finally, similar logistic regression analyses were conducted to examine the relationships
between substance use and two types of mental disorder comorbidities, i.e., anxiety comorbid
with depression, and anxiety comorbid with disruptive disorder(s), while controlling for
sociodemographic and other relevant variables. Here, too, Wald tests were used to test for
gender differences.
Results
NIH-PA Author Manuscript
Among 781 adolescents, 7.8% were smoking at least 1 cigarette per day, 19% were frequent
or heavy drinkers and 10.8% had engaged in illicit drug use in the year prior to the interview
(Table 2). About 8.6% met criteria for social phobia, 4.4% for agoraphobia, 8.6% for OAD/
GAD, 4.7% for separation anxiety, and 3.2% for OCD. Overall, 18.4% met criteria for any of
the assessed anxiety disorders. The prevalences of depressive and disruptive disorders were
9.6 and 11.5%, respectively. The prevalences of comorbid anxiety/depression, and of anxiety
comorbid with disruptive disorders, were each just under 5%.
The prevalences of frequent smoking and drug use were similar for the two genders. Frequent
or heavy drinking was more common among boys than among girls, but this difference was
only marginally significant. As expected, anxiety and depressive disorders were, in general,
more common among girls than boys. For social phobia and agoraphobia, as well as depression,
the gender differences were statistically significant, but they were not statistically significant
for the other three anxiety disorders. Comorbid anxiety/depression was more common among
girls (7.9%) than among boys (2.2%), while disruptive disorders were more prevalent in boys
than in girls.
NIH-PA Author Manuscript
Cigarette Smoking and Anxiety Disorders
Controlling for demographic and familial factors (Model 1 in Table 3), frequent cigarette
smoking was significantly associated with anxiety disorders in general for both boys (AOR =
3.0, p < .05) and girls (AOR = 3.3, p < .05). However, a significant gender difference was
found in the analyses on social phobia, which was significantly associated with smoking among
boys (AOR = 4.9, p < .01) but not among girls (AOR = .08, not significant). This gender
difference was statistically significant (p = .05). With regard to OAD/GAD, Separation
Anxiety, and OCD, on the other hand, significant associations with smoking were found for
girls but not for boys.
In order to take into account the fact that depression may be associated both with anxiety and
with substance use, depression was added into the equation in Model 2 (Table 3). After
depression was controlled for, the associations between smoking and anxiety disorders for girls
became noticeably weaker, indicating that depression may be either a confounder or a mediator
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 6
NIH-PA Author Manuscript
of the relationship between anxiety and smoking in girls. For example, the AORs for OCD and
smoking in girls dropped from 13.0 (p < .001) in Model 1–7.4 (p < .05) in Model 2. It is
interesting to note, however, that the AORs for boys were almost the same in Model 2 as in
Model 1, indicating that depression may not be a confounding factor for boys. After depression
was controlled for, the gender difference for social phobia remained significant.
Alcohol Use and Anxiety Disorders
With regard to alcohol use, no significant associations were found for boys between frequent/
heavy drinking and anxiety disorders when controlling for demographic and familial factors
(Model 1 in Table 4), while for girls frequent or heavy drinking was significantly associated
with any anxiety disorder and with number of anxiety disorders, as well as with two specific
anxiety disorders, i.e., agoraphobia and OCD.
After depression was controlled for (Model 2 in Table 4), any anxiety, number of anxiety
disorders, and agoraphobia were still significantly associated with frequent/heavy drinking
among girls, although the relationships became slightly weaker. The relationships for boys
remained non-significant. There was a significant gender difference, here, with regard to any
anxiety disorder; it was related to frequent/heavy drinking among girls, but not among boys.
Drug Use and Anxiety Disorders
NIH-PA Author Manuscript
Table 5 shows that, as with the analyses on frequent smoking and frequent/heavy drinking,
more significant associations were found for girls than for boys between illicit drug use and
anxiety disorders. The results for Model 1 show that, for boys, OCD was the only anxiety
disorder significantly associated with drug use (AOR = 4.1, p < .05). For girls, on the other
hand, agoraphobia, separation anxiety, and OCD were all significantly associated with drug
use. Again, when depression was controlled for the positive associations became somewhat
weaker. It is also worth mentioning that a marginally significant negative association between
social phobia and drug use in girls emerged here after controlling for depression (AOR = 0.2,
p < .10), indicating that girls with social phobia are less likely to use drugs than other girls.
The difference between girls and boys, with regard to social phobia and drug use, was
statistically significant.
Comorbid Anxiety/Depression and Anxiety Comorbid With Disruptive Disorders
NIH-PA Author Manuscript
The top half of Table 6 displays the results regarding the associations between anxiety
disorders, either alone or in combination with depression, and substance use. For boys, having
an anxiety disorder without depression was found to be associated with smoking (AOR = 3.2,
p = .013). Depression in boys was associated with past year drug use; the AORs here were 3.9
(p = .0234) for “Depressive Disorder(s) only”, and 9.5 (p = .005) for “Both”, indicating that
boys with both anxiety and depression may be at the greatest risk for drug use. Among girls,
having both anxiety and depression was predictive of smoking (AOR = 5.4, p = .006) and of
frequent/heavy drinking (AOR = 3.2, p = .021). “Anxiety Disorder(s) only” was predictive of
both frequent/heavy drinking (AOR = 2.8, p = .012) and of past year drug use (AOR = 3.4, p
= 0.010). These differences between the genders were not, however, statistically significant.
The bottom half of the table displays the results of similar analyses concerning the associations
of anxiety and disruptive disorders with substance use. As expected, the associations between
disruptive disorders and substance use were found to be stronger than those between anxiety
and substance use, for both genders. The association between “Disruptive Disorder(s) only”
and frequent/heavy drinking was significantly stronger among girls than among boys (with
AORs of 17.3 and 2.8, respectively), and the same was true for the relationship between anxiety
comorbid with disruptive disorders (“Both”), and frequent/heavy drinking (here the AORs
were 16.1 for girls, and 1.9 for boys).
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 7
Discussion
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Using data from a community sample, this study examined patterns of the co-occurrence of
anxiety disorders with use of different types of substances among adolescents, and the ways
in which these patterns differ by gender. This study’s findings, when combined with the
findings of studies examining these comorbidities among adults, shed light on the
developmental processes involved in changes in the relationships between anxiety disorders
and substance use and abuse which may occur over the life cycle. Significant gender differences
were found in the associations of social phobia with cigarette smoking and illicit drug use
among adolescents. Specifically, among boys, those with social phobia were significantly more
likely to be smokers, while among girls, those with social phobia actually appeared to be
somewhat less likely to smoke than those without, although this association was nonsignificant. It may be that boys are more susceptible than girls to engaging in tobacco use in
response to the self-presentation concerns that typically accompany social phobia. Among
girls, social phobia was found to be marginally negatively related to drug use. This indication
that rates of drug use, and of frequent smoking, may be lower among girls with social phobia
than among girls without it, is somewhat analogous to Kaplow et al. (2001) finding that
symptoms of separation anxiety are negatively related to alcohol use initiation among children
and adolescents. As these authors point out, the kinds of anxiety symptoms that tend to inhibit
a child or adolescent’s ability to form affiliations with his or her peer group may, as a result,
exert a protective effect against substance use initiation (Kaplow et al. 2001). Studies of adults,
however, have consistently found social phobia and drug use to be positively associated among
women (Buckner et al. 2006; Magee et al. 1996). Our findings indicate that the nature of social
phobia’s relationship with drug use may change during the transition from adolescence to
adulthood.
For the other four anxiety disorders assessed here (agoraphobia, OAD/GAD, separation
anxiety, and OCD), the associations with substance use among girls were frequently positive
and significant, while the associations for boys tended not to be significant. After we controlled
for depression along with other potentially confounding variables, significant associations
remained, among girls, between each of these four anxiety disorders and at least one category
of substance use—either smoking, drinking or illicit drug use. These stronger positive
associations for females than males are consistent with gender differences found in some
previous studies of both adults (Page and Andrews 1996) and youth (Patton et al. 2002; Patton
et al. 1996).
NIH-PA Author Manuscript
OCD was the specific anxiety disorder that showed the most consistent associations with
substance use among girls in our study, although after depression was controlled for its
association with alcohol use became marginal. The high rates of habit-based, repetitive, and
ritualized behaviors that typically accompany OCD may place girls who are afflicted with OCD
at greater risk of converting casual substance use into habit-based substance misuse. To our
knowledge, no previous studies have examined the relationship between OCD and tobacco use
among adolescents. One study did find OCD to be positively associated with dependence on
alcohol and illicit drugs among adolescents in New Zealand, consistently with our study; this
study did not, however, test for gender differences in these associations (Douglass et al.
1995). Our finding that OCD and smoking are significantly, and positively, associated among
girls, but not among boys, is analogous to the results of a community study done in northern
Germany, which found OCD to be positively related to smoking among women but not among
men (Grabe et al. 2001). However, it stands in contrast to the findings of clinical studies of
adults where both men and women with OCD were found to have very low rates of smoking
(Bejerot and Humble 1999; Himle et al. 1988). This difference in findings may have to do with
differences between community and clinical samples. Further research is needed to elucidate
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 8
the nature of the relationship between OCD and use of different types of substances, among
males and females, over time.
NIH-PA Author Manuscript
Another specific anxiety disorder with relatively strong associations with substance use among
the girls in our sample was agoraphobia, which was significantly associated both with alcohol
use and with illicit drug use. The finding of a positive relationship between agoraphobia and
alcohol use is consistent with Zimmermann and colleagues’ study of hazardous use of alcohol
in youth (Zimmermann et al. 2003), and Grant and colleagues’ findings on substance use
disorders in adults (Grant et al. 2004b). Girls may be particularly susceptible to engaging in
alcohol and drug use as a means of alleviating the fear of public and unfamiliar places that
characterizes agoraphobia.
NIH-PA Author Manuscript
Our study also examined the role of other mental disorders in the co-existence of anxiety
disorders with substance use. Our findings indicate that among adolescents of both genders,
those who have anxiety disorder(s) comorbid with other mental disorders (i.e., depressive or
disruptive disorders) are relatively likely to be substance users. However, girls may differ from
boys with similar mental disorder comorbidities, in terms of the types of substances chosen.
For example, among the girls, anxiety comorbid with depression was predictive of frequent
smoking, and of frequent/heavy drinking; while among the boys it was significantly predictive
of illicit drug use. This gender difference may be a reflection of differences in the general
popularity of particular types of substances of abuse, or in levels of involvement in substance
use, among boys and girls. A gender difference was also found with regard to anxiety comorbid
with disruptive disorders, which was significantly predictive of frequent/heavy drinking among
girls, but not among boys. These gender difference findings should be further explored in other
community, and preferably longitudinal, studies.
This study is limited by the cross-sectional nature of the data set, and no causal relationship
between substance use and anxiety disorders can be established. The low prevalence of
substance use disorders in this adolescent community sample precluded examination of
relationships between anxiety disorders and full-blown substance use disorders. The relatively
low prevalences of the specific anxiety disorders may have similarly limited our power to detect
gender differences in the associations between anxiety disorders and substance use. However,
the availability of information on these specific anxiety disorders, as measured by the NIMH
Diagnostic Interview Schedule for Children (Shaffer et al. 1996), in this probability sample of
community-dwelling adolescents, allowed us to offer unique insights into the relationship
between anxiety disorders and substance use in adolescence.
NIH-PA Author Manuscript
Most previous studies of adolescents have not examined gender differences in the associations
between specific anxiety disorders and the use of various specific types of substances. Our
findings suggest that the associations between substance use and anxiety may be specific to
particular anxiety disorders, as well as to particular types of substance use, and that the strengths
of these links may also be gender-specific. In general, the associations between anxiety
disorders and substance use were stronger among girls than among boys. Anxiety disorders
comorbid with disruptive disorders were also more consistently associated with higher rates
of heavy drinking and drug use among girls, than among boys. Social phobia was an exception
to this rule. The differences between the patterns observed in the current study’s adolescent
sample, and the findings of adult studies, with regard to social phobia, and to some extent OCD,
indicate that the relationship between anxiety disorders and substance use may change from
adolescence to adulthood. The findings also indicate the importance of recognizing and treating
childhood anxiety disorders, especially among girls, in order to help them avoid developing
secondary, comorbid substance use disorders.
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 9
Acknowledgments
Work on this paper was supported by a grant to the first author from the National Institute on Drug Abuse (DA013473).
NIH-PA Author Manuscript
References
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Agrawal A, Lynskey MT, Madden PA, Bucholz KK, Heath AC. A latent class analysis of illicit drug
abuse/dependence: Results from the National Epidemiological Survey on alcohol and related
conditions. Addiction (Abingdon, England) 2007;102(1):94–104.10.1111/j.1360–0443.2006.01630.x
Alonso J, Angermeyer M, Bernert S, Bruffaerts R, Brugha T, Bryson H, et al. 12-Month comorbidity
patterns and associated factors in Europe: Results from the European Study Of The Epidemiology Of
Mental Disorders (ESEMeD) Project. Acta Psychiatrica Scandinavica 2004;109(Suppl420):28–
37.10.1111/j.1600-0047.2004.00325.x
Angst J, Gamma A, Gastpar M, Lepine JP, Mendlewicz J, Tylee A, et al. Gender differences in depression.
Epidemiological findings from the European DEPRES I and II studies. European Archives of
Psychiatry and Clinical Neuroscience 2002;252(5):201–209.10.1007/s00406-002-0381-6 [PubMed:
12451460]
Armstrong TD, Costello E. Community studies on adolescent substance use, abuse, or dependence and
psychiatric comorbidity. Journal of Consulting and Clinical Psychology 2002;70(6):1224–
1239.10.1037/0022-006X.70.6.1224 [PubMed: 12472299]
Bejerot S, Humble M. Low prevalence of smoking among patients with obsessive-compulsive disorder.
Comprehensive Psychiatry 1999;40(4):268–272.10.1016/S0010-440X(99)90126-8 [PubMed:
10428185]
Book SW, Randall CL. Social anxiety disorder and alcohol use. Alcohol Research & Health 2002;26(2):
130–135.
Bott K, Meyer C, Rumpf HJ, Hapke U, John U. Psychiatric disorders among at-risk consumers of alcohol
in the general population. Journal of Studies on Alcohol 2005;66(2):246–253. [PubMed: 15957676]
Breslau N, Kilbey MM, Andreski P. Nicotine dependence and major depression new evidence from a
prospective investigation. Archives of General Psychiatry 1993;50(1):31–35. [PubMed: 8422219]
Breslau N, Peterson EL, Schultz LR, Chilcoat HD, Andreski P. Major depression and stages of smoking.
A longitudinal investigation. Archives of General Psychiatry 1998;55(2):161–166.10.1001/archpsyc.
55.2.161
Brook JS, Cohen P, Brook DW. Longitudinal study of co-occurring psychiatric disorders and substance
use. Journal of the American Academy of Child and Adolescent Psychiatry 1998;37(3):322–
330.10.1097/00004583-199803000-00018 [PubMed: 9519638]
Buckner JD, Mallott MA, Schmidt NB, Taylor J. Peer influence and gender differences in problematic
cannabis use among individuals with social anxiety. Journal of Anxiety Disorders 2006;20(8):1087–
1102.10.1016/j.janxdis.2006.03. 002 [PubMed: 16621436]
Burns L, Teesson M. Alcohol use disorders comorbid with anxiety, depression and drug use disorders:
Findings from the Australian National Survey of Mental Health and Well Being. Drug and Alcohol
Dependence 2002;68(3):299–307. 10.1016/S0376-8716(02)00220-X [PubMed: 12393224]
Christie KA, Burke JD, Regier DA, Rae DS, et al. Epidemiologic evidence for early onset of mental
disorders and higher risk of drug abuse in young adults. The American Journal of Psychiatry 1988;145
(8):971–975. [PubMed: 3394882]
Compton WM, Thomas YF, Stinson FS, Grant BF. Prevalence, correlates, disability, and comorbidity of
DSM-IV drug abuse and dependence in the United States: Results from the National Epidemiologic
Survey on Alcohol and Related Conditions. Archives of General Psychiatry 2007;64(5):566–
576.10.1001/archpsyc.64.5.566 [PubMed: 17485608]
Costello EJ, Erkanli A, Federman E, Angold A. Development of psychiatric comorbidity with substance
abuse in adolescents: Effects of timing and sex. Journal of Clinical Child Psychology 1999;28(3):
298–311.10.1207/S15374424jccp280302 [PubMed: 10446679]
Douglass HM, Moffitt TE, Dar R, McGee R, et al. Obsessive-compulsive disorder in a birth cohort of
18-year-olds: Prevalence and predictors. Journal of the American Academy of Child and Adolescent
Psychiatry 1995;34(11):1424–1431.10.1097/00004583-199511000-00008 [PubMed: 8543509]
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 10
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Eisen JL, Rasmussen SA. Coexisting obsessive compulsive disorder and alcoholism. The Journal of
Clinical Psychiatry 1989;50(3):96–98. [PubMed: 2784431]
Falk DE, Yi Hy, Hilton ME. Age of onset and temporal sequencing of lifetime DSM-IV alcohol use
disorders relative to comorbid mood and anxiety disorders. Drug and Alcohol Dependence 2008;94
(1–3):234–245.10.1016/j.drugalcdep.2007.11.022 [PubMed: 18215474]
Goodman SH, Hoven CW, Narrow WE, Cohen P, Fielding B, Alegria M, et al. Measurement of risk for
mental disorders and competence in a psychiatric epidemiologic community survey: The National
Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders
(MECA) study. Social Psychiatry. Sozialpsychiatrie Psychiatrie Sociale 1998;33(4):162–173.
Grabe HJ, Meyer C, Hapke U, Rumpf HJ, Freyberger HJ, Dilling H, et al. Lifetime-comorbidity of
obsessive-compulsive disorder and subclinical obsessive-compulsive disorder in northern Germany.
European Archives of Psychiatry and Clinical Neuroscience 2001;251(3):130–135.10.1007/
s004060170047 [PubMed: 11697574]
Grant BF, Hasin DS, Chou S, Stinson FS, Dawson DA. Nicotine dependence and psychiatric disorders
in the United States. Archives of General Psychiatry 2004a;61(11):1107–1115.10.1001/archpsyc.
61.11.1107 [PubMed: 15520358]
Grant BF, Stinson FS, Dawson DA, Chou P, Dufour MC, Compton W, et al. Prevalence and co-occurrence
of substance use disorders and independent mood and anxiety disorders: Results from the National
Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 2004b;
61(8):807–816.10.1001/archpsyc.61.8.807 [PubMed: 15289279]
Gratzer D, Levitan RD, Sheldon T, Toneatto T, Rector NA, Goering P. Lifetime rates of alcoholism in
adults with anxiety, depression, or co-morbid depression/anxiety: A community survey of Ontario.
Journal of Affective Disorders 2004;79(1–3):209–215.10.1016/S0165-0327(02)00355-5 [PubMed:
15023496]
Grothues JM, Bischof G, Reinhardt S, Meyer C, John U, Rumpf HJ. Effectiveness of brief alcohol
interventions for general practice patients with problematic drinking behavior and comorbid anxiety
or depressive disorders. Drug and Alcohol Dependence 2008;94(1–3):214–220.10.1016/
j.drugalcdep.2007. 11.015 [PubMed: 18207336]
Hall W, Farrell M. Comorbidity of mental disorders with substance misuse. The British Journal of
Psychiatry 1997;171:4–5.10.1192/bjp.171.1.4 [PubMed: 9328485]
Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of Major Depressive Disorder: Results
From the National Epidemiologic Survey on Alcoholism and Related Conditions. Archives of
General Psychiatry 2005;62(10):1097–1106.10.1001/archpsyc.62.10.1097 [PubMed: 16203955]
Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSMIV alcohol abuse and dependence in the United States: Results from the National Epidemiologic
Survey on Alcohol and Related Conditions. Archives of General Psychiatry 2007;64(7):830–
842.10.1001/archpsyc.64.7.830 [PubMed: 17606817]
Helzer JE, Pryzbeck TR. The co-occurrence of alcoholism with other psychiatric disorders in the general
population and its impact on treatment. Journal of Studies on Alcohol 1988;49(3):219–224. [PubMed:
3374135]
Himle J, Thyer BA, Fischer DJ. Prevalence of smoking among anxious outpatients. Phobia Practice &
Research Journal 1988;1(1):25–31.
Johnson JG, Cohen P, Pine DS, Klein DF, Kasen S, Brook JS. Association between cigarette smoking
and anxiety disorders during adolescence and early adulthood. Journal of the American Medical
Association 2000;284(18):2348–2351.10.1001/jama.284.18.2348 [PubMed: 11066185]
Kandel DB, Johnson JG, Bird HR, Canino G, Goodman SH, Lahey BB, et al. Psychiatric disorders
associated with substance use among children and adolescents: Findings from the Methods For The
Epidemiology Of Child And Adolescent Mental Disorders (MECA) Study. Journal of Abnormal
Child Psychology 1997;25(2):121–132.10.1023/A:1025779412167 [PubMed: 9109029]
Kaplow JB, Curran PJ, Angold A, Costello E. The prospective relation between dimensions of anxiety
and the initiation of adolescent alcohol use. Journal of Clinical Child Psychology 2001;30(3):316–
326.10.1207/S15374424JCCP3003_4 [PubMed: 11501249]
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 11
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Kessler RC, Berglund P, Demler O, Jin R, Walters EE. Lifetime prevalence and age-of-onset distributions
of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General
Psychiatry 2005;62(6):593–602. 10.1001/archpsyc.62.6.593 [PubMed: 15939837]
Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC. Lifetime co-occurrence of
DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National
Comorbidity Survey. Archives of General Psychiatry 1997;54(4):313–321. [PubMed: 9107147]
Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Frank RG, Leaf PJ. The epidemiology of cooccurring addictive and mental disorders: Implications for prevention and service utilization. The
American Journal of Orthopsychiatry 1996;66(1):17–31.10.1037/h0080151 [PubMed: 8720638]
Keyes KM, Martins SS, Hasin DS. Past 12-month and lifetime comorbidity and poly-drug use of ecstasy
users among young adults in the United States: Results from the National Epidemiologic Survey on
Alcohol and Related Conditions. Drug and Alcohol Dependence 2008;97(1–2):139–149. 10.1016/
j.drugalcdep.2008.04.001 [PubMed: 18524499]
Kolada J, Bland R, Newman S. Obsessive-compulsive disorder. Acta Psychiatrica Scandinavica 1994;89
(376):24–35. 10.1111/j.1600-0447.1994.tb05788.x
Kovalenko PA, Hoven CW, Wu P, Wicks J, Mandell DJ, Tiet Q. Association between allergy and anxiety
disorders in youth. The Australian and New Zealand Journal of Psychiatry 2001;35(6):815–
821.10.1046/j.1440-1614.2001. 00961.x [PubMed: 11990892]
Kushner MG, Sher KJ, Beitman BD. The relation between alcohol problems and the anxiety disorders.
The American Journal of Psychiatry 1990;147(6):685–695. [PubMed: 2188513]
Kushner MG, Sher KJ, Erickson DJ. Prospective analysis of the relation between DSM-III anxiety
disorders and alcohol use disorders. The American Journal of Psychiatry 1999;156(5):723–732.
[PubMed: 10327905]
Lahey BB, Flagg EW, Bird HR, Schwab-Stone ME, Canino G, Dulcan MK, et al. The NIMH methods
for the epidemiology of child and adolescent mental disorders (MECA) study: Background and
methodology. Journal of the American Academy of Child and Adolescent Psychiatry 1996;35(7):
855–864.10.1097/00004583-199607000-00011 [PubMed: 8768345]
Lepine JP, Wittchen HU, Essau CA. Lifetime and current comorbidity of anxiety and affective disorders:
Results from the International WHO/ADAMHA CIDI Field Trials. International Journal of Methods
in Psychiatric Research 1993;3(2):67–77.
Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. Agoraphobia, simple phobia, and
social phobia in the national comorbidity survey. Archives of General Psychiatry 1996;53(2):159–
168. [PubMed: 8629891]
Merikangas KR, Stevens D, Fenton B, Stolar M, O’Malley S, Woods S, et al. Co-morbidity and familial
aggregation of alcoholism and anxiety disorders. Psychological Medicine 1998;28(4):773–
788.10.1017/S0033291798006941 [PubMed: 9723135]
Page AC, Andrews G. Do specific anxiety disorders show specific drug problems? . The Australian and
New Zealand Journal of Psychiatry 1996;30(3):410–414.10.3109/00048679609065007 [PubMed:
8839954]
Patton GC, Coffey C, Carlin JB, Degenhardt L, Lynskey M, Hall W. Cannabis use and mental health in
young people: Cohort study. BMJ 2002;325(7374):1195.10.1136/bmj. 325.7374.1195 [PubMed:
12446533]
Patton GC, Hibbert M, Rosier MJ, Carlin JB, Caust J, Bowes G. Is smoking associated with depression
and anxiety in teenagers? . American Journal of Public Health 1996;86(2):225–230.10.2105/AJPH.
86.2.225 [PubMed: 8633740]
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL. Comorbidity of mental disorders with
alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. Journal
of the American Medical Association 1990;264(19):2511–2518.10.1001/jama.264.19.2511
[PubMed: 2232018]
Rohde P, Lewinsohn PM, Seeley JR. Psychiatric comorbidity with problematic alcohol use in high school
students. Journal of the American Academy of Child and Adolescent Psychiatry 1996;35(1):101–
109.10.1097/00004583-199601000-00018 [PubMed: 8567601]
Schwab-Stone ME, Shaffer D, Dulcan MK, Jensen PS, Fisher P, Bird HR. Criterion validity of the NIMH
Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3). Journal of the American
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 12
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Academy of Child and Adolescent Psychiatry 1996;35(7):878–
888.10.1097/00004583-199607000-00013 [PubMed: 8768347]
Shaffer D, Fisher P, Dulcan MK, Davies M. The NIMH Diagnostic Interview Schedule for Children
Version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECA
study. Journal of the American Academy of Child and Adolescent Psychiatry 1996;35(7):865–
877.10.1097/00004583-199607000-00012 [PubMed: 8768346]
Sung M, Erkanli A, Angold A, Costello E. Effects of age at first substance use and psychiatric comorbidity
on the development of substance use disorders. Drug and Alcohol Dependence 2004;75(3):287–
299.10.1016/j.drugalcdep.2004.03.013 [PubMed: 15283950]
Suzuki K, Muramatsu T, Takeda A, Shirakura K. Co-occurrence of obsessive-compulsive personality
traits in young and middle-aged Japanese alcohol-dependent men. Alcoholism Clinical and
Experimental Research 2002;26(8):1223–1227.
Wittchen HU, Essau CA, Krieg JC. Anxiety disorders: Similarities and differences of comorbidity in
treated and untreated groups. The British Journal of Psychiatry 1991;159(Suppl 12):23–33.10.1192/
bjp.159.5.645
Wu P, Bird HR, Liu X, Fan B, Fuller C, Shen S, et al. Childhood depressive symptoms and early onset
of alcohol use. Pediatrics 2006;118(5):1907–1915.10.1542/peds.2006-1221 [PubMed: 17079561]
Young SE, Corley RP, Stallings MC, Rhee SH, Crowley TJ, Hewitt JK. Substance use, abuse and
dependence in adolescence: Prevalence, symptom profiles and correlates. Drug and Alcohol
Dependence 2002;68(3):309–322.10.1016/S0376-8716(02)00225-9 [PubMed: 12393225]
Zimmermann G, Pin MA, Krenz S, Bouchat A, Favrat B, Besson J, et al. Prevalence of social phobia in
a clinical sample of drug dependent patients. Journal of Affective Disorders 2004;83(1):83–
87.10.1016/j.jad.2004.05.003 [PubMed: 15546650]
Zimmermann P, Wittchen H, Hofler M, Pfister H, Kessler R, Lieb R. Primary anxiety disorders and the
development of subsequent alcohol use disorders: A 4-year community study of adolescents and
young adults. Psychological Medicine 2003;33(7):1211–1222.10.1017/S0033291703008158
[PubMed: 14580076]
Biographies
Ping Wu is an Associate Professor of Psychiatry and Epidemiology at Columbia University.
She received her Ph.D. in Applied Social Research from Lehigh University, and was a
Postdoctoral Fellow in Psychiatric Epidemiology at Columbia University. Her primary
research interests include substance use and comorbid psychiatric disorders, especially
internalizing disorders, among adolescents.
NIH-PA Author Manuscript
Renee D. Goodwin is an Associate Professor of Epidemiology at Columbia University. She
received her Ph.D. in Psychology from Northwestern University. Her primary research
interests include the relationship between anxiety disorders and other health and mental health
issues; she has conducted extensive research on the relationship between childhood asthma
and mental disorders.
Cordelia Fuller is a Research Scientist at the New York State Psychiatric Institute. She
received an M.A. in Development Economics from the University of Wisconsin. She has
research interests in the comorbidity of mental health and substance abuse problems in
adolescents, and in the influence of nutrition on children’s mental health.
Xinhua Liu is an Associate Professor of Biostatistics at Columbia University. She received
her Ph.D. in Biostatistics from Johns Hopkins University. Her research interests include
substance use in adult and adolescents, and statistical methods for research on comorbidity.
Jonathan S. Comer is a Research Fellow at Columbia University in the Division of Child and
Adolescent Psychiatry. He received his Ph.D. in clinical psychology from Temple University
with a concentration in developmental psychopathology. His major research interests include
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 13
the etiology and treatment of childhood anxiety disorders, as well as the effects of political
violence and other disasters on youth.
NIH-PA Author Manuscript
Patricia Cohen is a Professor of Clinical Epidemiology in Psychiatry at Columbia University.
She received her Ph.D. in Social Psychology from New York University. Her research interests
include mental health over the life span, and the relationship between mental health and
comorbid substance use/abuse.
Christina W. Hoven is an Associate Professor of Epidemiology in Psychiatry at Columbia
University. She received her Doctorate in Public Health from Columbia University. Her
research interests include psychopathology, especially PTSD, among adolescents, as well as
adolescent mental health service utilization.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 14
Table 1
Sample characteristics (N = 781)
NIH-PA Author Manuscript
Total
(N = 781)
Boys
(N = 412)
Girls
(N = 369)
Girl (%)
47.3
–
–
Age (Mean)
15.0
15.0
15.0
White
48.9
49.0
48.8
African-American
17.4
17.0
17.9
Hispanic
27.1
29.4
24.7
6.5
4.6
8.7
Ethnicity (%)
Other
Public assistance (%)
10.9
10.0
12.0
Not living with both Biological parents (%)
40.5
39.8
41.2
5.1
4.4
6.0
Parental drug/alcohol problems (%)
NIH-PA Author Manuscript
NIH-PA Author Manuscript
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 15
Table 2
NIH-PA Author Manuscript
Substance use, anxiety and other disorders, by gendera
Total (N = 781) (%)
Boys (N = 412) (%)
Girls (N = 369) (%)
Smoked at least 1 cigarette/day, past
6 months
7.8
7.8
7.9
Frequent or heavy drinking, past 6
months
19.0
21.4
16.3+
Illicit drug use, past year
10.8
10.0
11.7
Social Phobia
8.6
6.6
10.8*
Agoraphobia
4.4
2.7
6.2*
OAD/GADb
8.6
7.3
10.0
Separation anxiety
4.7
3.9
5.7
OCDc
3.2
2.4
4.1
18.4
14.8
22.5**
0.29 (0.72)
0.23 (0.03)
0.37 (0.80)**
Any depressive disorder
9.6
6.8
12.7**
Any disruptive disorder
11.5
15.5
7.1***
Anxiety disorder with depressive
disorder
4.9
2.2
7.9***
Anxiety disorder with disruptive
disorder
4.9
5.3
4.3
Anxiety disorders
Any anxiety disorder
NIH-PA Author Manuscript
Number of anxiety disorders (Mean
(SD))
a
Values are percentages, except where otherwise noted
b
Overanxious disorder/generalized anxiety disorder
c
Obsessive-compulsive disorder
+
p < 0.10;
*
p < 0.05;
**
p < 0.01;
***
NIH-PA Author Manuscript
p < 0.001
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Table 3
OCD AOR (CI)
Any anxiety AOR
(CI)
No. of anxiety
disorders AOR
(CI)
1.8 (0.4–9.6)
1.1 (0.1–9.2)
3.0* (1.3–7.0)
1.7* (1.0–2.8)
6.5** (2.1–20.3)
5.4* (1.4–21.2)
13.0*** (2.3–73.2)
3.3* (1.3–8.0)
2.1* (1.3–3.3)
NA
NS
NS
NS
NS
NS
4.8** (1.6–14.8)
–d
2.8+ (0.9–8.5)
1.8 (0.4–9.4)
1.1 (0.1–9.4)
2.9* (1.2–6.9)
1.7* (1.0–2.7)
0.5 (0.1–2.0)
3.0 (0.6–13.7)
4.4* (1.2–15.8)
3.9+ (1.0–15.7)
7.4* (1.1–47.8)
2.4+ (0.9–6.5)
1.8* (1.0–3.0)
p = .0138
NA
NS
NS
NS
NS
NS
Social phobia AORa
(CI)b
Agoraphobia AOR (CI)
Boys
4.9** (1.6–15.1)
Girls
OAD/GAD AOR (CI)
Separation anxiety
AOR (CI)
–d
2.9+ (1.0–8.8)
0.8 (0.2–3.3)
3.2 (0.7–14.1)
p = .0505
Boys
Girls
Wu et al.
Results of logistic regression analyses of frequent smoking on anxiety disorders, by gender
Model 1c
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Gender
Differencee
Model 2f
Gender
Differencee
a
AOR = adjusted odds ratio
b
CI = 95% Confidence interval
c
Controlling for age, ethnicity, public assistance, not living with both biological parents, parental drug/alcohol problems and site
d
No estimates available because of empty cells (no boy had co-occurring agoraphobia and smoking)
e
A p value for gender difference is listed here if the AORs for boys and girls, for the particular anxiety disorder, were found to be significantly different, using the Wald test for equality of coefficients; NS =
not significant; NA = not available
f
In addition to the variables controlled for in model 1, depressive disorders were also controlled for here
+
p < 0.10;
*
p < 0.05;
**
p < 0.01;
***
p < 0.001
Page 16
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Table 4
Social phobia AORa
(CI)b
Agoraphobia AOR (CI)
OAD/GAD AOR (CI)
Separation anxiety
AOR (CI)
OCD AOR (CI)
Any anxiety AOR
(CI)
No. of anxiety
disorders AOR (CI)
Boys
0.9 (0.3–2.7)
1.6 (0.3–8.2)
0.9 (0.3–2.5)
2.4 (0.7–8.3)
1.3 (0.3–5.7)
1.0 (0.5–2.0)
1.1 (0.7–1.7)
Girls
1.4 (0.5–3.4)
3.6* (1.2–10.9)
2.4+ (1.0–6.0)
3.0+ (0.9–9.4)
5.2* (1.3–20.9)
2.9** (1.5–5.7)
1.7** (1.2–2.4)
NS
NS
NS
NS
NS
p = .0340
NS
Boys
0.9 (0.3–2.6)
1.6 (0.3–8.1)
0.8 (0.3–2.3)
2.3 (0.7–7.8)
1.3 (0.3–5.6)
0.9 (0.5–2.0)
1.1 (0.7–1.6)
Girls
1.1 (0.4–2.9)
3.5* (1.1–10.5)
2.0 (0.7–5.3)
2.5 (0.8–8.2)
4.1+ (0.8–17.2)
2.7** (1.3–5.6)
1.6* (1.1–2.4)
NS
NS
NS
NS
NS
p = .0479
NS
Wu et al.
Results of logistic regression analyses of frequent/heavy drinking on anxiety disorders, by gender
Model 1c
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Gender
Differenced
Model 2e
Gender
Differenced
a
AOR = adjusted odds ratio
b
CI = 95% confidence interval
c
Controlling for age, ethnicity, public assistance, not living with both biological parents, parental drug/alcohol problems and site
d
A p value for gender difference is listed here if the AORs for boys and girls, for the particular anxiety disorder, were found to be significantly different, using the Wald test for equality of coefficients; NS =
not significant
e
In addition to the variables controlled for in model, depressive disorders were also controlled for here
+
p < 0.10;
*
p < 0.05;
**
p < 0.01
Page 17
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Table 5
OCD AOR (CI)
Any anxiety AOR
(CI)
No. of anxiety
disorders AOR
(CI)
1.1 (0.2–5.8)
4.1* (0.9–18.6)
2.3+ (1.0–5.2)
1.5 (0.9–2.3)
2.4 (0.8–7.0)
6.1** (1.7–22.5)
7.9* (1.5–40.3)
2.6* (1.2–5.7)
1.6* (1.0–2.5)
NS
NS
NS
NS
NS
NS
1.8 (0.5–5.5)
1.3 (0.1–12.6)
1.4 (0.4–4.4)
1.0 (0.2–5.1)
4.2+ (1.0–18.8)
2.1 (0.9–4.7)
1.3 (0.8–2.1)
0.2+ (0.04–1.1)
4.3* (1.2–13.7)
2.1 (0.6–6.6)
5.6* (1.5–21.2)
6.7* (1.2–38.3)
2.5* (1.1–5.8)
1.6+ (1.0–2.6)
p = .0349
NS
NS
NS
NS
NS
NS
Social phobia AORa
(CI)b
Agoraphobia AOR (CI)
Boys
2.1 (0.7–6.6)
Girls
OAD/GAD AOR (CI)
Separation anxiety
AOR (CI)
1.2 (0.1–11.8)
1.9 (0.6–5.6)
0.3 (0.1–1.4)
4.4* (1.2–16.0)
p = .0455
Boys
Girls
Wu et al.
Results of logistic regression analyses of illicit drug use on anxiety disorders, by gender
Model 1c
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Gender
Differenced
Model 2e
Genderd
Difference
a
AOR = adjusted odds ratio
b
CI = 95% confidence interval
c
Age, ethnicity, public assistance, not living with both biological parents, parental drug/alcohol problems and site were controlled for
d
A p value for gender difference is listed here if the AORs for boys and girls, for the particular anxiety disorder, were found to be significantly different, using the Wald test for equality of coefficients; NS =
not significant
e
In addition to the variables controlled for in Model 1, depressive disorders were also controlled for here
+
p < 0.10;
*
p < 0.05;
**
p < 0.01
Page 18
Wu et al.
Page 19
Table 6
Results of logistic regression analyses of substance use behaviors on types of mental disorders, by gender
NIH-PA Author Manuscript
Frequent or
heavy drinking
AOR (CI)
Illicit drug use
AOR (CI)
Neither anxiety nor
depressive disorderd
1
1
1
Anxiety disorder(s) only
3.2 (1.3–7.9)*
0.9 (0.4–2.1)
2.0 (0.8–5.0)
Depressive disorder(s) only
1.9 (0.5–7.9)
1.8 (0.6–.1)
3.9 (1.2–12.6)*
Both
3.0 (0.3–27.1)
1.7 (0.3–9.1)
9.5 (2.0–12.6)**
Neither anxiety nor
depressive disorderd
1
1
1
Anxiety disorder(s) only
2.8 (0.9–8.8)
2.8 (1.3–6.4)*
3.4 (1.3–8.8)*
Depressive disorder(s) only
3.2 (0.7–15.0)
1.5 (0.4–.5)
2.5 (0.6–10.1)
Both
5.4 (1.6–18.0)**
3.2 (1.2–8.5)*
2.1 (0.6–6.7)
Gender
Anxiety disorder(s) only
NS
p = .0566
NS
Differencee
Depressive disorder(s) only
NS
NS
NS
Both
NS
NS
NS
Neither anxiety nor
disruptive disorderd
1
1
1
Anxiety disorder(s) only
2.1 (0.5–8.3)
0.9 (0.4–2.3)
2.0 (0.6–6.1)
Disruptive disorder(s) only
10.4 (3.6–30.0)***
2.8 (1.3–6.1)**
3.7 (1.4–9.7)**
Both
22.8 (6.1–85.9)***
1.9 (0.6–5.7)
5.5 (1.6–18.6)**
Neither anxiety nor
disruptive disorderd
1
1
1
Anxiety disorder(s) only
1.6 (0.5–5.3)
2.8 (1.2–6.4)
2.7 (1.0–7.2)*
Disruptive disorder(s) only
7.3 (1.0–52.8)*
17.3 (3.5–84.9)***
25.0 (4.6–136.8)***
Both
26.9 (4.8–150.6)***
16.1 (3.9–66.9)***
16.2 (3.3–78.4)***
Gender
Anxiety disorder(s) only
NS
NS
NS
Differencee
Disruptive disorder(s) only
NS
p = 0443
p = .0542
Both
NS
p = .0199
NS
Anxiety and/or depressive disorder(s)c
Boys
Girls
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Frequent smoking
AORa (CI)b
Anxiety and/or disruptive disorder(s)f
Boys
Girls
a
AOR = adjusted odds ratio
b
CI = 95% confidence interval
c
Age, ethnicity, public assistance, not living with both biological parents, parental drug/alcohol problems, and site were controlled for in this set of
analyses
d
Reference group
e
A p value for gender difference is listed here if the AORs for boys and girls, for the specified type of mental disorder, were found to be significantly
different, using the Wald test for equality of coefficients; NS = not significant
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.
Wu et al.
Page 20
f
Age, ethnicity, public assistance, not living with both biological parents, parental drug/alcohol problems, site and depressive disorder were controlled
for in this set of analyses
+
p < 0.10;
NIH-PA Author Manuscript
*
p < 0.05;
**
p < 0.01,
***
p < 0.001
NIH-PA Author Manuscript
NIH-PA Author Manuscript
J Youth Adolesc. Author manuscript; available in PMC 2011 February 1.