Prevalence of Anxiety Disorder Comorbidities in Female Outpatients with Substance Use Disorder in a Referral Public Psychiatric Hospital in Tehran, Iran

Document Type : Original article

Authors

Research Center of Addiction and Risky Behavior, Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

Abstract

Background: Nowadays, the attention to the combination of Substance Use Disorders (SUD) and anxiety disorders in women is increasing; therefore, the aim of this study was to investigate the prevalence of anxiety disorders in women substance users and epidemiological features of this population.
Methods: In a cross-sectional study, 48 female outpatients with SUD referred to the Iran psychiatric hospital substance use clinic with a range of 18 to 65 years, were involved in the study. All participants referred to the substance use clinic of Iran psychiatric center to follow up on the comorbidities and psychiatric disorders, were involved in the study. The Structured Clinical Interview for DSM-5 (SCID) was used to anxiety disorders and SUD diagnoses. The SCID is a semi-structured interview guide for making the major DSM-5 diagnoses. It is administered by a clinician who is familiar with the DSM-5 classification and diagnostic criteria. Finally, gathered data were analyzed by SPSS-22.
Results: Totally, 48 patients enrolled to this study. The mean age of patients was 34.2±9.4. Crystal (60.4%) and alcohol (50%) were the most commonly used substances. Of the 48 substance users, 47.9% had at least one type of anxiety disorders. The most common anxiety disorders in substance users were generalized anxiety disorder (37.5%), social anxiety disorder (18.8%), and agoraphobia and panic disorder (12.5%). A statistically significant correlation was found between agoraphobia and opium (p=0.04), generalized anxiety disorders and benzodiazepines (p=0.02).
Conclusion: In the present study, it was shown that anxiety disorders co-occur with SUD at a high rate. Generalized anxiety disorders and social anxiety disorder were the two most prevalent conditions among substance users. Analysis showed a statistically significant correlation between agoraphobia and opium, general anxiety disorders and benzodiazepines.

Keywords


Abstract
Background: Nowadays, the attention to the combination of Substance Use Disorders (SUD) and anxiety disorders in women is increasing; therefore, the aim of this study was to investigate the prevalence of anxiety disorders in women substance users and epidemiological features of this population.
Methods: In a cross-sectional study, 48 female outpatients with SUD referred to the Iran psychiatric hospital substance use clinic with a range of 18 to 65 years, were involved in the study. All participants referred to the substance use clinic of Iran psychiatric center to follow up on the comorbidities and psychiatric disorders, were involved in the study. The Structured Clinical Interview for DSM-5 (SCID) was used to anxiety disorders and SUD diagnoses. The SCID is a semi-structured interview guide for making the major DSM-5 diagnoses. It is administered by a clinician who is familiar with the DSM-5 classification and diagnostic criteria. Finally, gathered data were analyzed by SPSS-22.
Results: Totally, 48 patients enrolled to this study. The mean age of patients was 34.2±9.4. Crystal (60.4%) and alcohol (50%) were the most commonly used substances. Of the 48 substance users, 47.9% had at least one type of anxiety disorders. The most common anxiety disorders in substance users were generalized anxiety disorder (37.5%), social anxiety disorder (18.8%), and agoraphobia and panic disorder (12.5%). A statistically significant correlation was found between agoraphobia and opium (p=0.04), generalized anxiety disorders and benzodiazepines (p=0.02).
Conclusion: In the present study, it was shown that anxiety disorders co-occur with SUD at a high rate. Generalized anxiety disorders and social anxiety disorder were the two most prevalent conditions among substance users. Analysis showed a statistically significant correlation between agoraphobia and opium, general anxiety disorders and benzodiazepines.
Keywords:  Anxiety disorder, Comorbidity, Substance use 

Introduction 
Anxiety Disorders (ADs) are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear which may cause physical and cognitive symptoms (1,2). According to the population-based studies, up to 33.7% of people experience an anxiety disorder during their lifetime, but its overall prevalence decreases in elders (3,4). In Iran, anxiety disorders among children and adolescents are estimated with the prevalence rates ranging from 6.8% in Saravan to 85% in Bandar Abbas. In another study in Iran, the 12-month prevalence of anxiety disorders was 15.6%, also the prevalence was 12% in males and 19.4% in females (5,6). In a multinational evaluation, the one-year and lifetime prevalence of anxiety disorders was estimated at about 10.6% and 16.6%, respectively. The lowest prevalence was observed in East Asia at 2.8% and the highest in North Africa and the Middle East at 7.7%. Women with a prevalence of 30.5% over a lifetime are more likely to be interfaced with anxiety disorders than men, (with the ratio of 2 to1) (7-9). 
Substance use is one of the most important health social and political problems all over the world and the highest prevalence is observed among young people (10,11). The prevalence of substance use in Iran is in a range between 2.8 to 15.4% (12,13). In several studies, 46% of people mentioned opium and 23.5% cannabis as the first substance and the most common substance use in the women population was opium (81%). The main causes of substance use onset were family history of dependency (77%), easy access to substances (64%), and depression and hopelessness (56%) (14-18). Associations between ADs and Substance Use Disorders (SUDs) may also differ depending on the type of anxiety and also lead to more symptom severity and functional impairment (19-21). Prospective studies have found greater support to risk for development of a SUD among those with ADs than vice versa. In a 10-year follow-up comorbidity survey, individuals with an AD were significantly more likely to develop SUD (22-26). Anxiety disorders co-occur with SUDs at a high rate in both the general population and in treatment-seeking samples. The co-occurrence of these disorders is associated with greater symptom severity, higher levels of disability, and a poorer course of illness relative to either disorder alone (27,28). Unfortunately, in Iran, females with SUDs are highly stigmatized. Women are considered the core of family, and in the context of substance use, they will be exposed to discrimination and exclusion. Most Iranian women who use substances reside in an inappropriate and unhealthy home situation (29,30). Due to the lack of similar studies regarding the prevalence of anxiety disorders comorbidities in female with SUDs, the present study aimed to evaluate the prevalence of anxiety disorders comorbidities in female outpatients with SUD of a referral public psychiatric hospital.

Materials and Methods
Study design
In a cross-sectional study, we investigated 48 female outpatients with SUD referred to the Iran psychiatric hospital, with a range of 18 to 65 years, based on the available facilities and time limitation, from April 2020 to March 2021. All participants were substance users, referred to the substance use clinic of Iran psychiatric center to follow up on the comorbidities and psychiatric disorders, and according to inclusion and exclusion criteria, the eligible patients were involved in the study. The Structured Clinical Interview for DSM-5 (SCID) was used for anxiety disorders and SUD diagnoses.

Inclusion and exclusion criteria    
Inclusion criteria were as follows, signing informed consent, lack of psychotic signs and symptoms due to acute major periods (major depression and mania). Patients who withdrew from the clinical interview in the middle of the project, were excluded.

Data collection
Written informed consent was taken from the patients. Interviews, which were performed by a psychiatric resident, took between 1-2 hours, depending on the patients’ complexity and their ability to describe current episodes and previous symptoms. A standardized questionnaire was utilized to collect socio-demographic data including age, level of education, a brief history of medical illnesses and psychiatric disorders (including previous hospitalizations), use of certain medications, smoking, other substances, alcohol, and duration of use were recorded.
The SCID is a sem-istructured interview guide for making the major DSM-5 diagnoses. It is administered by a clinician or a trained mental health professional who is familiar with the DSM-5 classification and diagnostic criteria, to determine DSM-5 axis I disorders (31,32). Current psychopathology was assessed by interviewers using an adapted version of the research version of the SCID (31). The following disorders were assessed: SUD, panic disorder, agoraphobia, social anxiety disorder, and generalized anxiety disorder. We utilized the Persian translation of the SCID-5, which was administered by Mohammadkhani. SCID psychometric properties indicated the range for test-retest reliability (0.60-0.79), Kappa reliability (0.57-0.72), and validity (0.63-0.83) (33). The SCID has several advantages, for instance, probing and clarifying the questions and their answers cannot be distorted by the respondents’ reading level, which allows for assessing a wide area of psychopathology categorically or dimensionally and accurately capturing the multifactorial nature of psychopathology (34).

Data analysis
Data were analyzed by IBM SPSS STATISTICS 22 (IBM Inc, New York, USA). Data are presented as numbers and percentages and compared between groups by chi-square test. p values less than 0.05 were assumed as statistically significant.

Results
In this study, 48 female outpatients with SUD were involved. The mean age of patients was 34.2±9.4 and about 81.3% of patients were urban residents. The minimum age of consumption onset was 18 years and the maximum age was 32 years with a mean age of 19.08±5.1. Of the total patients, 33.3% were married and the others were single or divorced and about 29.3% of the patients had a history of legal conflicts. 14.6% of the patients had a bachelor or higher degrees and 72.9% of the patients were housewives and had no monthly income. 47.9% had a history of hospitalization due to psychiatric or SUD and about 27.1% had a history of outpatient treatment for substance use. The most common anxiety disorder in substance-using patients was generalized anxiety disorder (37.5%), social anxiety disorder (18.8%), agoraphobia, and panic had the lowest prevalence (12.5%). The most common substances used were cigarettes (93.7%), crystals (60.4%) and alcohol (50%) The methods of substance use are illustrated in figure 1. Of the 48 substance users, 23 (47.9%) had at least one type of anxiety disorders. The analysis showed that opium use was significantly associated with agoraphobia (p=0.02), and general anxiety disorder was significantly associated with benzodiazepine use (p=0.04) (Table 1).

 

Table 1. Relation between substance use and anxiety disorders

 

 

Panic Disorder

Social Anxiety Disorder

Agoraphobia

General Anxiety Disorder

Crystal

(%)

Nb=29

Yes

No

Pa

2(6.9)

4(21.1)

0.147

4(13.8)

5(26.3)

0.277

2(6.9)

4(21.1)

0.147

9(31)

9(47.4)

0.253

Cannabis

(%)

N=21

Yes

No

P

2(9.5)

4(14.8)

0.414

2(9.5)

7(25.9)

0.149

2(9.5)

4(14.8)

0.414

7(33.3)

11(40.7)

0.599

Opium

(%)

N=22

Yes

No

P

1(4.5)

5(19.2)

0.125

3(13.6)

6(23.1)

0.404

3(13.6)

4(11.5)

0.04

9(40.9)

9(34.6)

0.654

Heroin

(%)

N=16

Yes

No

P

2(12.5)

4(12.5)

1

3(18.8)

6(18.8)

1

2(12.5)

4(12.5)

1

8(50)

10(31.2)

0.206

Methadone

(%)

N=19

Yes

No

P*

1(5.3)

5(17.2)

0.220

3(15.8)

6(20.7)

0.671

1(5.3)

5(17.2)

0.220

7(36.8)

11(37.9)

0.939

Tramadol

(%)

N=13

Yes

No

P

0

6(17.1)

0.111

1(7.7)

8(22.9)

0.232

0

6(17.1)

0.111

4(30.8)

14(40)

0.557

LSDc

(%)

N=4

Yes

No

P

0

6(13.6)

0.430

0

9(20.5)

0.316

0

6(13.6)

0.430

1(25)

17(38.6)

0.590

Benzodiazepine

(%)

N=25

Yes

No

P

1(7.1)

5(21.7)

0.155

1(7.1)

5(21.7)

0.387

1(7.1)

5(21.7)

0.155

8(32)

10(43.5)

0.02

ap.value

bNumber

cLysergic acid diethylamide

 

Discussion
Interest in surveying the co-occurrence of anxiety disorders and SUDs has grown tremendously in recent years. Some evaluations have investigated the needs, anxiety, and consequences of psychiatric patients with comorbid substance use and patients who do not utilize substances, and it was revealed that psychiatric patients with comorbidity of substance use reported more unsatisfied needs, inadequate nutrition, inappropriate housing, and anxiety (35,36). Adequate research has not been conducted on the comorbidities of anxiety disorders and substance use in female population. Within this context, this study was one of the first studies carried out in our country about the association between different types of anxiety disorders and SUDs in the females (28). 
This study showed that the majority of consumers were women of the lower half of society’s living standards. Most of them were unemployed, with low education and with a low-income level, similar to our study, in another study, 48.1% of the patients were from those lower than the middle class, all of which seem to predispose the possibility of substance use (37). The most common anxiety disorders in substance users were generalized anxiety disorders and social anxiety disorder. Some evaluations have reported that generalized anxiety disorder occurs after the onset of dependency and that almost all anxiety disorders are positively associated with substance use. A survey conducted by Wittchen about anxiety disorders with comorbid SUDs, showed that SUDs are one of the most common comorbid psychiatric disorders among individuals with a generalized anxiety disorder. Recent epidemiological studies noted that GAD was the anxiety disorder most often associated with using alcohol or substances to self-medicate symptoms; therefore, the mentioned reports were similar to our assessment (5,6,38-40). Fernandez et al showed that anxiety disorders were associated with patients taking heroin and benzodiazepines. In another survey conducted by Bakken et al in 2005, it was found that the prevalence of social anxiety disorder was higher in multiple substance users (51%). Also, in a study published in the United States, a history of past substance use was particularly linked to an increased risk of social anxiety disorder and agoraphobia (41-43). Our investigation showed that among females who use substances, 47.9% had at least one type of anxiety disorders, but in the general population, the prevalence of anxiety disorder is much lower. Several studies in general populatin reported that about 7% of the adolescents had social anxiety disorder (44). The 12-month prevalence of anxiety disorders was 15.6%. The prevalence was 12% in males and 19.4% in females. The most prevalent anxiety disorders were generalized anxiety disorder (5.2%) and social phobia (3.2%) (45). In an other survey, pooled 1-year and lifetime prevalence rates for total anxiety disorders were 10.6% and 16.6%. Women had generally higher prevalence rates across all anxiety disorder categories (46). An investigation showed that nicotine-dependent subjects (70.4% of the sample) had significantly more anxiety disorders compared to the non-dependent ones. It seems that anxiety disorder has a strong role in the initiation of smoking; therefore, higher anxiety rates were reported in the group of smokers (47). This difference in prevalence beween user and non-users population, could simply exist since anxiety disorders tend to have an onset in early adolescence, prior to the average onset of SUDs, or could be because social phobia specifically increases the risk for SUDs. Perhaps experiencing anxiety in adolescence makes a young person more prone to peer pressure, due to anxiety about fitting in, which would be a risk factor for developing SUDs. Also some people may use substances occasionally to reduce anxiety symptoms, however, alcohol and substance use can be associated with a reduction in the effectiveness of drug therapies. 

Conclusion
In sum, the present study showed that anxiety disorders co-occur with SUDs at a high rate. Generalized anxiety disorders and social anxiety disorder were the two most prevalent conditions among substance users. Analysis showed a statistically significant correlation between agoraphobia and opium, general anxiety disorders, and benzodiazepines.

Limitation
There were several limitations: the first one was was to contact and interview the patient due to covid-19 isolation. Second, this study was based on retrospective reports, and prospective studies may provide more reliable estimates. This study failed to show the time sequence, for example, social phobia and agoraphobia almost always occur before the SUD. Thus, studies that examine the temporal relationship between anxiety and SUDs are required.

Suggestion
According to the results, we suggest evaluating the other psychiatric comorbidities in substance users. It seems to be necessary to survey anxiety disorders in larger sample size and different geographical areas. It is also needed to design studies to evaluate the effectiveness of medication and psychotherapy interventions for the treatment of comorbid anxiety disorders in women with substance dependency.

Ethical issues
In this study, no intervention was performed on patients. Informed consent was taken from the patients. If a person refused to participate in the study, she would not be deprived of any medical services. All personal information remained confidential.

Acknowledgements 
Ethics ID; IR.IUMS.FMD.REC.1399.140. We wish to thank the Iran Psychiatric Hospital substance use clinic, which helped us complete this study. 

  1. Pires AJ, Casanova CC, Quevedo Lde A, Jansen K, Silva RA. Panic disorder and psychoactive substance use in primary care. Trends Psychiatry Psychother 2014 Jun; 36:113–8. https://pubmed.ncbi.nlm.nih.gov/27000711/
  2. Groenman AP, Janssen TW, Oosterlaan J. Childhood psychiatric disorders as risk factor for subsequent substance abuse: a meta-analysis. J Am Acad Child Adolesc Psychiatry 2017 Jul; 56:556-69 https://pubmed.ncbi.nlm.nih.gov/28647007/.
  3. Martin P. The epidemiology of anxiety disorders:a review. Dialogues Clin Neurosci 2003 Sep;5:281-98. https://pubmed.ncbi.nlm.nih.gov/22034470/
  4. Bandelow B, Michaelis S. Epidemiology of anxiety disorders in the 21st century. Dialogues Clin Neurosci 2015 Sep;17:327–35. https://pubmed.ncbi.nlm.nih.gov/26487813/
  5. Hajebi A, Motevalian SA, Rahimi-Movaghar A, Sharifi V, Amini-Esmaeili M, Radgoodarzi R, et al. Major anxiety disorders in Iran: prevalence, sociodemographic correlates and service utilization. BMC Psychiatry 2018 Aug 20;18(1):261. https://pubmed.ncbi.nlm.nih.gov/30126386/
  6. Zarafshan H, Mohammadi MR, Salmanian M. Prevalence of Anxiety Disorders among Children and Adolescents in Iran: A Systematic Review. Iran J Psychiatry 2015;10(1):1-7. https://pubmed.ncbi.nlm.nih.gov/26005473/
  7. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughers M, Eshleman S, et al. Life time and 12-month prevalence of DSM-III-R psychiatric disorder in the United States. Arch Gen Psychiatry 1994 Jan;51(1):8-19. https://pubmed.ncbi.nlm.nih.gov/8279933/
  8. Baxter AJ, Scott KM, Ferrari AJ, Norman RE, Vos T, Whiteford HA. Challenging the myth of an “epidemic” of common mental disorders: trends in the global prevalence of anxiety and depression between 1990 and 2010. Depress Anxiety 2014 Jun;31(6):506-16. https://pubmed.ncbi.nlm.nih.gov/24448889/
  9. Steel, Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, et al. The global prevalence of common mental disorders: a systematic review and meta–analysis 1980–2013. Int J Epidemiol 2014 Apr;43(2):476-93. https://pubmed.ncbi.nlm.nih.gov/24648481/
  10. Mojahed A, Bakhshani NM. Prevalence of smoking and drug abuse in students of Zahedan high schools. Zahedan J Res Med Sci 2004;6(1):59–65.  
  11. Siam S. Drug abuse prevalence between male students of different universities in Rasht in 2005. Zahedan J Res Med Sci. 2007;8(4):279–85. 
  12. Babaei Heidarabadi A, Ramezankhani A, Barekati H, Vejdani M, Shariatinejad K, Panahi R, et al. Prevalence of substance abuse among dormitory students of Shahid Beheshti University of Medical Sciences, Tehran, Iran. Int J High Risk Behav Addict 2015 Jun 20;4(2):e22350. https://pubmed.ncbi.nlm.nih.gov/26405679/
  13. Shalbafan M, Donboli S, Salehian R. Effect of variable substances on sexual function: A narrative review. J Iran Med Council 2019 Sep 1;2(5):112-9.
  14. Daneshmandan N, Narenjiha H, Tehrani K, Assari S, Khoddami-Vishteh HR. Initiation to the First Drug Use Among Substance-Dependent Persons in Iran. Subst Use Misuse 2011;46(9):1124-41. https://pubmed.ncbi.nlm.nih.gov/21345165/
  15. Nakhaee N, Divsalar K, Meimandi MS, Dabiri S. Estimating the Prevalence of Opiates Use by Unlinked Anonymous Urine Drug Testing: A Pilot Study in Iran. Substance Use Misuse 2008;43(3-4):513-20. https://pubmed.ncbi.nlm.nih.gov/18365947/
  16. Magidson JF, Liu SM, Lejuez CW, Blanco C. Comparison of the course of substance use disorders among individuals with and without generalized anxiety disorder in a nationally representative sample. J Psychiatr Res 2012 May;46:659–66. https://pubmed.ncbi.nlm.nih.gov/22444600/
  17. Banafsheh HR, Mesdaghinia A, Ghoreishi FS, Gilasi HR, Kashani Z, Gholami M, et al. The survey of pattern of abusing and causes of addiction tendency among women undergoing methadone maintenance treatment in Kashan city during 2017-2018. Feyz J Kashan Uni Med Sci 2018; 22(5): 532-8.
  18. Schneider U, Altmann A, Baumann M, Bernzen J, Bertz B, Bimber U, et al. Comorbid anxiety and affective disorder in alcohol-dependent patients seeking treatment: the first Multicentre Study in Germany. Alcohol Alcohol 2001;36:219–23. https://pubmed.ncbi.nlm.nih.gov/11373258/ 
  19. Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, et al. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. Am J Psychiatry 2005 Jun;162:1179–87. https://pubmed.ncbi.nlm.nih.gov/15930067/
  20. Boschloo L, Vogelzangs N, van den Brink W, Smit JH, Veltman DJ, Beekman ATF, et al. Alcohol use disorders and the course of depressive and anxiety disorders. Br J Psychiatry 2012 Jun;200:476–84. https://pubmed.ncbi.nlm.nih.gov/22322459/
  21. Groenman AP, Janssen TW, Oosterlaan J. Childhood psychiatric disorders as risk factor for subsequent substance abuse: a meta-analysis. J Am Acad Child Adolesc Psychiatry 2017 Jul;56:556–69. https://pubmed.ncbi.nlm.nih.gov/28647007/
  22. Johnson JG, Cohen P, Pine DS, Klein DF, Kasen S, Brook JS. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA 2000 Nov 8;284:48-51. https://pubmed.ncbi.nlm.nih.gov/11066185/
  23. Roberts MC, Emsley RA, Pienaar WP, Stein DJ. Anxiety disorders among abstinent alcohol-dependent patients. Psychiatr Serv 1999 Oct;50:1359–61.https://pubmed.ncbi.nlm.nih.gov/10506309/
  24. Lopez B, Turner RJ, Saavedra LM. Anxiety and risk for substance dependence among late adolescents/young adults. J Anxiety Disord 2005;19:275–94. https://pubmed.ncbi.nlm.nih.gov/15686857/
  25. Swendsen J, Conway KP, Degenhardt L, Glantz M, Jin R, Merikangas KR, et al. Mental disorders as risk factors for substance use, abuse and dependence: results from the 10-year follow-up of the National Comorbidity Survey. Addiction 2010 Jun;105:1117–28. https://pubmed.ncbi.nlm.nih.gov/20331554/
  26. Buckner JD, Timpano KR, Zvolensky MJ, Sachs-Ericsson N, Schmidt NB. Implications of comorbid alcohol dependence among individuals with social anxiety disorder. Depress Anxiety 2008;25:1028–1037. https://pubmed.ncbi.nlm.nih.gov/18781667/
  27. Pardini D, White HR, Stouthamer-Loeber M. Early adolescent psychopathology as a predictor of alcohol use disorders by young adulthood. Drug Alcohol Depend 2007 Apr;88S:S38–S49. https://pubmed.ncbi.nlm.nih.gov/17257781/
  28. de Matos MB, de Mola CL, Trettim JP, Jansen K, da Silva RA, Souza LDM, et al. Psychoactive substance abuse and dependence and its association with anxiety disorders: a population-based study of young adults in Brazil. Braz J Psychiatry 2018 Oct-Dec;40(4):349-353. https://pubmed.ncbi.nlm.nih.gov/29451585/
  29. Merghati-Khoei E, Rimaz S, Korte JE, Back SE, Brady KT, Abad M, et al. Intimate partner violence and risky sexual behaviors among. Med J Islam Repub Iran 2015 Feb 7;29:174. https://pubmed.ncbi.nlm.nih.gov/26034727/
  30. Rahimi Movaghar A, Malayerikhah Langroodi Z, Delbarpour Ahmadi S, Amin Esmaeili M. A qualitative study of specific needs of women for treatment of addiction. Iran J Psychiatr Clin Psycholy 2011;17(2):116–25.
  31. First MB, Williams JBW, Karg RS, Spitzer RL. Structured clinical interview for DSM-5—Research version (SCID-5 for DSM-5, research version; SCID-5-RV). Arlington, VA: American Psychiatric Association. 2015.
  32. 32. Shabani A, Masoumian S, Zamirinejad S, Hejri M, Pirmorad T, Yaghmaeezadeh H. Psychometric properties of Structured Clinical Interview for DSM-5 Disorders-Clinician Version (SCID-5-CV). Brain Behav 2021 May;11(5):e01894.
  33. Mohammadkhani P, Forouzan AS, Hooshyari Z, Abasi I. Psychometric Properties of Persian Version of Structured Clinical Interview for DSM-5-Research Version (SCID-5-RV): A Diagnostic Accuracy Study, Iran J Psychiatry Behav Sci 2020 Jun 30 ; 14(2):e100930.
  34. Chinka JA. Further issues in determining the readability of self-report items: Comment on McHugh and Behar (2009). J Consult Clin Psychol 2012 Oct;80(5):952-5. https://pubmed.ncbi.nlm.nih.gov/22924333/
  35. Back SE, Brady KT. Anxiety Disorders with Comorbid Substance Use Disorders: Diagnostic and Treatment Considerations. Psychiatr Ann 2008 Nov;38(11):724-729. https://pubmed.ncbi.nlm.nih.gov/20717489/
  36. Soraya S, Haghshenas M, Ahmadkhaniha HR, Azarnik S, MansourKiaei H, Rassouli S, et al. Needs of Spouses of Patients with Substance Use Disorder: A Qualitative Study. J Iran Med Council 2021 Jun 20; 4(2): 86-92.
  37. McCabe RE, Chudzik SM, Antony MM, Young L, Swinson RP, Zolvensky MJ. Smoking behaviors across anxiety disorders. J Anxiety Disord 2004;18:7-18. https://pubmed.ncbi.nlm.nih.gov/14725865/
  38. Marmorstein NR. Anxiety disorders and substance use disorders: different associations by anxiety disorder. J Anxiety Disord 2012 Jan;26(1):88-94. https://pubmed.ncbi.nlm.nih.gov/22018969/
  39. Wittchen HU, Zhao S, Kessler RC, Eaton WW. DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1994 May;51(5):355–364. https://pubmed.ncbi.nlm.nih.gov/8179459/
  40. Bolton JM, Sareen J. Lifetime mood, anxiety, and drug use disorders are common in the United States population. Evid Based Ment Health 2006 Nov;9(4):113. https://pubmed.ncbi.nlm.nih.gov/17065310/
  41. Fernández Miranda J, González García-Portilla M, Sáiz Martínez P, Gutiérrez Cienfuegos E, Bobes García J. Influence of psychiatric disorders in the effectiveness of a long-term methadone maintenance treatment. Actas Esp Psiquiatr 2001 Jul-Aug;29(4):228-32. https://pubmed.ncbi.nlm.nih.gov/11470057/
  42. Bakken K, Landheim AS, Vaglum P. Substance-dependent patients with and without social anxiety disorder: occurrence and clinical differences. A study of a consecutive sample of alcohol-dependent and poly-substance-dependent patients treated in two counties in Norway. Drug Alcohol Depend 2005 Dec 12;80(3):321-8. https://pubmed.ncbi.nlm.nih.gov/15964156/
  43. 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. Arch Gen Psychiatry 2007 May;64(5):566-.576. https://pubmed.ncbi.nlm.nih.gov/17485608/
  44. Rabe-Jabłońska J, Dietrich-Muszalska A, Gmitrowicz A. The prevalence of social phobia in a representative group of adolescents from Łódź. Psychiatr Pol 2003 Jan 1;37(1):87-95. https://pubmed.ncbi.nlm.nih.gov/12685306/
  45. Hajebi A, Motevalian SA, Rahimi-Movaghar A, Sharifi V, Amin-Esmaeili M, Radgoodarzi R, et al. Major anxiety disorders in Iran: prevalence, sociodemographic correlates and service utilization. BMC Psychiatry 2018 Dec;18(1):1-8. https://pubmed.ncbi.nlm.nih.gov/30126386/
  46. Somers JM, Goldner EM, Waraich P, Hsu L. Prevalence and incidence studies of anxiety disorders: a systematic review of the literature. Can J Psychiatry 2006 Feb;51(2):100-13. https://pubmed.ncbi.nlm.nih.gov/16989109/
  47. Compton 3rd WM, Cottler LB, Jacobs JL, Ben-Abdallah A, Spitznagel EL. The role of psychiatric disorders in predicting drug dependence treatment outcomes. Am J Psychiatry 2003 May;160(5):890-5. https://pubmed.ncbi.nlm.nih.gov/12727692/