Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Feb 22.
Published in final edited form as: Cogn Behav Ther. 2017 Jul 5;46(6):478–492. doi: 10.1080/16506073.2017.1336185

Synergistic effects of pain and alcohol use in relation to depressive and anxiety symptoms among Latinos in primary care

Daniel J Paulus a, Andres G Viana a,b, Joseph W Ditre c, Jafar Bakhshaie a, Monica Garza d, Jodi Berger Cardoso e, Jeanette Valdivieso d, Melissa Ochoa-Perez d, Chad Lemaire d, Michael J Zvolensky a,f
PMCID: PMC11846058  NIHMSID: NIHMS2053918  PMID: 28678618

Abstract

Although past work has shown that alcohol use co-occurs with anxiety/depression among Latinos, little work has examined the variables that qualify such associations. The present investigation sought to address whether pain severity (i.e. pain intensity and/or pain-related disability, respectively) moderated relations between hazardous drinking and depressive/anxious arousal symptoms among an economically disadvantaged Latino sample recruited from a primary care medical setting. Participants included 253 adult Latinos (Mage = 38.5 years, SD = 10.8; 86.6% female) who attended a community-based primary care clinic. There was a significant interaction of hazardous drinking with pain intensity in relation to depressive symptoms and significant interactions of hazardous drinking and pain-related disability in relation to depressive and anxious arousal symptoms. Hazardous drinking was associated with more severe depressive/anxious arousal symptoms only when pain intensity/disability was high. This is the first study to demonstrate the moderating role of pain intensity and disability in associations between hazardous drinking and anxiety/depression among Latinos in a primary care medical setting.

Keywords: Pain, alcohol, transdiagnostic, comorbidity, health disparity

Latinos are the largest and among the most quickly growing racial/ethnic groups in the United States ([US]; Stepler & Brown, 2016; US Census Bureau, 2010). Unfortunately, Latinos in the US face significant mental health disparities relative to non-Hispanic Whites (Ortega, Rodriguez, & Bustamante, 2015; United States Department of Health and Human Services [USDHHS], 2001). Some work suggests that rates of depression and anxiety symptoms among Latinos may be twice as large as the rate observed among non-Hispanic Whites (Alegría, Canino, Stinson, & Grant, 2006; Alegría, Molina, & Chen, 2014), whereas other work finds no differences between Latinos and other racial/ethnic groups (Asnaani, Richey, Dimaite, Hinton, & Hofmann, 2010). Increased rates of depression and anxiety among Latinos are associated with adverse health conditions and outcomes (Zimmerman, Mast, Miles, & Markides, 2009), including somatic problems (Wassertheil-Smoller et al., 2014), chronic health problems (e.g. diabetes; Fisher, Chan, Nan, Sartorius, & Oldenburg, 2012), and substance use (Substance Abuse & Mental Health Services Administration [SAMHSA], 2013).

There is a need to broaden our understanding of other factors (e.g. health behaviors) that may be related to anxiety/depression among Latinos. Increasing scholarly recognition has been placed on the role of increased substance use as one common behavioral health problem that may be related to poorer mental health among this group (Vaeth, Caetano, & Rodriguez, 2012). Some research suggests that Latinos consume significantly larger quantities of alcohol than non-Hispanic Whites (Chartier & Caetano, 2010). For example, 42.4% of Latinos consume three or more drinks on a drinking day, compared to 31.6% of non-Hispanic Whites (Centers for Disease Control & Prevention, 2014). In addition to consumption, past work has found Latina women to be at greater risk for developing alcohol abuse and dependence relative to non-Hispanic White women (Grant et al., 2012). English-speaking Hispanics/Latino men, especially those born in the US, have a higher lifetime prevalence rate of Alcohol Use Disorder (AUD) than non-Hispanic White men and foreign-born Latino men (Grant, Stinson, Hasin et al., 2004). AUD among Latinos tends to be more persistent relative to other racial/ethnic groups (Dawson et al., 2006). Clinical and epidemiological data substantiate a high co-occurrence of alcohol use, hazardous drinking (the use of alcohol putting one at risk for alcohol-related problems), and anxiety/depression among Latinos (Vaughan, Robbins, & Escobar, 2014). Other work suggests that individuals with clinical anxiety and depression are 30%–60% more likely to endorse heavy drinking and/or meet criteria for alcohol use disorder; effects not explained by concurrent psychopathology and other forms of substance use problems (Grant, Stinson, Dawson et al., 2004). Although this body of research suggests hazardous drinking may be related to anxiety and depression among Latinos, little work has sought to explicate factors that may qualify such relations.

Clinical and epidemiological data substantiate a high co-occurrence of pain and substance use (Morasco et al., 2011) and in particular, pain and alcohol consumption (Zale, Maisto, & Ditre, 2015). Although extant research on pain and pain-related factors among Latinos is limited in scope (Green et al., 2003), there is evidence that pain severity and overall distress are greater among Latinos compared to non-Hispanic Whites (e.g. Gagnon, Matsuura, Smith, & Stanos, 2014), possibly due to poorly controlled and persistent pain (Cintron & Morrison, 2006). Despite seeking treatment for pain, Latinos experience more barriers to appropriate pain treatment (e.g. language barriers, cultural barriers in physician–patient communication, and stoicism) relative to other groups (Cintron & Morrison, 2006). Among Latinos, pain severity has been associated with greater anxiety and depressive symptoms (Hastie, Riley, & Fillingim, 2005; Hernandez & Sachs-Ericsson, 2006; Paulus, Bakhshaie, Garza et al., 2016; Velasco et al., 2016) as well as disability (Edwards, Moric, Husfeldt, Buvanendran, & Ivankovich, 2005). Moreover, there is some evidence that Latinos tend to endorse a greater number of somatic symptoms associated with mental health problems relative to other cultural groups (e.g. Simon, Von Korff, Piccinelli, Fullerton, & Ormel, 1999). However, research has not yet examined pain severity as a moderating factor in relations between hazardous drinking and anxiety and depressive symptoms in general or among Latinos.

Theoretically, pain severity and hazardous drinking may interact such that in the presence of greater pain severity, a Latino individual may use alcohol to manage pain, which may result in greater depressive and anxiety symptoms. Conversely, when pain severity is low/not present, alcohol use may not be associated with greater anxiety/depression. Accordingly, Latinos who are experiencing more severe pain may be more likely to drink to cope/dampen the experience of pain (e.g. Zale et al., 2015), increasing the probability of more intense anxiety/depressive symptoms. Overall, these findings suggest that hazardous drinking Latinos may represent a heterogeneous group regarding key facets of anxiety/depression symptoms and that variation in pain severity may be an important factor in accounting for such differences.

The purpose of the present investigation was to examine the moderating role of pain severity in hazardous drinking–anxiety/depression relations among an economically disadvantaged Latino sample that was recruited from a primary care medical setting. Groups with low socioeconomic status, such Latinos in urban environments, have a greater risk for chronic pain conditions and greater risk for poor outcomes to pain treatment (Institute of Medicine, 2011). Pain severity was indexed by both pain intensity and pain-related disability, which have been deemed to be two important features of pain (Von Korff, 2011). Due partially to such factors as stigma associated with seeking mental health care, primary care settings represent an ideal point of contact for early intervention in Latino mental health (Vega & Lopez, 2001). It was hypothesized that the association between hazardous drinking and anxiety/depression would be moderated by pain intensity and pain-related disability, such that the hazardous drinking–anxiety/depression associations would be strongest for those with greater pain intensity and pain-related disability. The moderating effects were expected to be observed after accounting for theoretically relevant covariates of participant sex, marital status, years of education, years in the US, and negative affectivity, given that these factors have been consistently linked to both depression and anxiety in previous research (Alegría et al., 2007; Grant, Stinson, Hasin et al., 2004; Melkevik et al., 2016; Paulus, Talkovsky, Heggeness, & Norton, 2015; Rana et al., 2016).

Method

Latino adults (N = 253; Mage = 38.5 years, SD = 10.8; 86.6% female) were recruited from a primary care health clinic located in a large southwestern city as part of a larger ongoing study examining mental health among Latinos. More than half (60.1%) identified their ethnicity as Mexican/Mexican-American with 24.1% as Central American, 5.5% as American/Born in the United States, 5.1% as South American, 1.6% as Cuban, .4% as Dominican, and 3.2% as “other.” Regarding marital status, 44.3% were married, 17.8% were living with partner, 28.9% were single, 7.1% were divorced, and 2.0% were widowed. Just over one-quarter (25.7%) of those reporting employment status were employed full-time (40 h a week), 14.2% were employed part-time (20 h a week), 10.1% were employed less than 20 h a week, 39.9% were unemployed, and 10.1% were looking for employment; 13.8% did not indicate employment status. Income data were available for 32.4% of the sample (n = 82); initially, income was not included in the demographic sample. Of those, the majority (89.0%) had a household income of less than $35,000 annually, with 20.7% reporting less than $5000, 12.2% between $5000 and $9999, 19.5% between $10,000 and $14,999, 22.0% between $15,000 and $24,999, 14.6% between $25,000 and $34,999, 9.8% between $35,000 and $49,999, and 1.2% with $50,000 or greater. Individuals listed their reasons for attending the clinic as follows: family medicine (28.1%), dental (9.5%), blood/urine/lab test (5.1%), accompanying someone/other reasons (28.5%), and 24.1% did not indicate a reason. Regarding psychopathology (per the Mini International Neuropsychiatric Interview [MINI], see below), 32.4% of the sample met criteria for a current psychiatric disorder. Of those with a diagnosis, there was an average of 1.9 diagnoses present (SD = 1.2); 18.6% had major depression, 7.5% posttraumatic stress disorder, 7.1% panic, 5.1% generalized anxiety disorder, 4.7% alcohol use disorder, 4.0% dysthymia, 3.6% substance use disorder, 3.2% social phobia, and 3.2% obsessive compulsive disorder. The majority (95.3%) reported Spanish as their first language.

Measures

Demographics

A demographics questionnaire was used to gather information such as age, gender, ethnicity, and marital status.

MINI International Neuropsychiatric Interview (MINI; Lecrubier et al., 1997)

Diagnostic assessments were performed using the MINI. The MINI provides quick and reliable DSM-IV diagnoses, which is applicable to research settings (Lecrubier et al., 1997) and has demonstrated sound interrater and test–retest reliability and validity (Sheehan et al., 1997). The interviews were administered by trained, Spanish-speaking staff (bachelor level or higher) and supervised by an independent doctoral-level rater. Approximately 12% of randomly selected interviews were checked (JB) for accuracy, and no cases of diagnostic coding disagreement were noted. The MINI was used for sample description in the current study.

Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988)

The PANAS is a self-report measure of affect. Each of 20 different feelings and emotions (e.g. interested, nervous) are rated on a Likert scale that ranges from 1 “very slightly or not at all” to 5 “extremely” based on how the respondent generally feels (i.e. trait negative affectivity). The measure yields two subscales (negative and positive affectivity) with strong psychometric properties (Watson et al., 1988). The negative affectivity subscale (PANAS-NA) was used in the present investigation and had good internal consistency (Cronbach’s α = .84), consistent with past work among Spanish-speaking Latinos (Zvolensky et al., 2016).

Graded Chronic Pain Scale (GCPS; Von Korff, Ormel, Keefe, & Dworkin, 1992)

The GCPS is a self-report measure of current pain. Items are rated on Likert scales from 0 (e.g. “no pain”) to 10 (e.g. “pain as bad as it could be)”. Three items (e.g. “How would you rate your pain now?”) assess pain intensity (GCPS-Intensity), and three items (e.g. “How much has the pain changed your ability to work [including homework]?”) assess pain-related disability (GCPS-Disability). The GCPS has good reliability and validity (Von Korff, 2001), and has been used successfully among Spanish-speaking samples (Velasco et al., 2016). GCPS scores can be used descriptively to categorize pain into five categories. Grade 1 is low pain-related disability and low pain intensity; Grade 2 is low pain-related disability and high pain intensity; Grade 3 is high pain-related disability with moderate limitations; Grade 4 is high-related disability with severe limitations (for details, see; Von Korff et al., 1992). In the current study, internal consistency was good for GCPS-Intensity (Cronbach α = .87) and excellent for the GCPS-Disability (Cronbach α = .93).

The Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993)

The AUDIT is a widely used self-report measure of hazardous drinking consisting of 10 questions (e.g. “How often do you have a drink containing alcohol?”) that are rated on scales from 0 (e.g. “never”) to 4 (e.g. “4 or more times a week”). The AUDIT is a reliable and valid measure of hazardous drinking (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001; Saunders et al., 1993), including among Spanish-speaking respondents (Paulus, Bakhshaie, Lemaire et al., 2016; Saitz, Lepore, Sullivan, Amaro, & Samet, 1999). In the current sample, internal consistency was acceptable for the AUDIT-Total (Cronbach α = .78).

Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007)

The IDAS is a self-report instrument assessing distinct affect symptom dimensions. Items are answered on a five-point Likert scale ranging from “not at all” to “extremely” regarding degree of experience within the past two weeks. The IDAS subscales show strong internal consistency, convergent and discriminant validities with psychiatric diagnoses, and self-report measures as well as short-term retest reliability with both community and psychiatric patient samples (Watson et al., 2007, 2008). The current study used the 20-item general depression subscale (e.g. “I felt depressed”) and the 8-item anxious arousal subscale (e.g. “my heart was racing or pounding”). Internal consistency was excellent for the depressive (α = .90) and anxious arousal (α = .90) subscales, respectively, similar to past work using these subscales among Spanish-speaking Latinos (Zvolensky et al., in press).

Procedure

All procedures were conducted in Spanish (written and oral). Individuals attending a community-based primary care integrated health care clinic were invited for study participation. Following written informed consent, interested individuals completed various demographic, psychological, and medical assessments. The study protocol was approved by the Institutional Review Board at the University of Houston. Upon completion, individuals were compensated $20 each. Participants were included if they reported the ability to read, write, and communicate in Spanish. Participants were excluded if they exhibited limited mental competency (not oriented to person, place, or time) or the inability to provide informed, voluntary, written consent. Individuals were not selected based on mental health concerns.

Analytic strategy

Correlations among study variables were examined first. Next, data were screened for normality. Then, four separate hierarchical regression analyses were used to examine main and interactive effects of pain intensity (GCPS-Intensity) and hazardous drinking (AUDIT), and pain-related disability (GCPS-Disability) and hazardous drinking, in relation to depressive (IDAS-Depressive) and anxious arousal (IDAS-Anxious Arousal) symptoms. Predictors were centered at their respective means. Covariates (sex, marital status, education, years in the U.S., and negative affectivity) were entered in the first step, main effects entered in the second step, and the interaction in the third step. Standardized coefficients (β) are reported throughout. Planned simple slope post hoc analyses were conducted for significant interactions using high and low values (e.g. ±1 SD from the mean) of the moderator variable(s), GCPS-Intensity and GCPS-Disability, respectively, to examine effects of hazardous drinking with depressive and anxiety symptoms as a function of pain (e.g. Holmbeck, 2002). Finally, the Johnson–Neyman technique (JN; Aiken & West, 1991) was used to statistically identify regions of values in the moderator where the effect of the predictor (hazardous drinking) on the criterion variables (depressive and anxiety symptoms) was statistically significant, per recommendations of Hayes (2013). Additionally, the JN technique identifies the point(s) at which the effect of the predictor on the criterion changes from being statistically non-significant to statistically significant (and vice versa), providing more detail than simple slope analysis. Alternative models were also run examining interactions of anxious arousal and depression and pain-related constructs (intensity and disability) in relation to hazardous drinking to serve as comparisons for the hypothesized interactive models. These models were run given the cross-sectional design; reversing the predictor and outcome was expected to yield non-significant interactions.

Results

Descriptive statistics

Correlations are presented in Table 1. Data were slightly positively skewed .9–3.5 (George & Mallery, 2003). However, variables were Winsorized to correct for skew and results did not change. Therefore, results using untransformed values are presented throughout. Pain intensity and pain-related disability were strongly correlated (r = .65, p < .001), but not redundant. Pain intensity and pain-related disability were each significantly correlated with depressive and anxiety symptoms (r’s from .44 to .48, p’s < .001). Neither pain intensity nor pain-related disability was significantly associated with hazardous drinking (p’s > .05). Per the GCPS, 14.2% reported pain below grade 1, 60.1% of the sample reported grade 1 pain, 8.3% reported grade 2 pain, 13.0% reported grade 3 pain, and 4.3% reported grade 4 pain.

Table 1.

Zero-order correlations among study variables (N = 253).

Variable 1 2 3 4 5 6 7 8 9 10
1. Sex (female)a –
2. Marital statusa −.02 –
3. Years of educationa .01 −.04 –
4. years in the USa −.04 −.04 .06 –
5. PANAS-NAa −.06 −.09 −.07 −.05 –
6. GCPS-Intensityb .07 −.10 −.09 .01 .35** –
7. GCPS-Disabilityb −.01 −.07 −.04 .10 .45** .65** –
8. AUDlTb −.30** −.04 .02 .01 .01 .01 −.03 –
9. lDAS-Depressivec −.09 −.17** −.15* −.05 .70** .44** .48** .06 –
10. IDAS-Anxious Arousalc −.09 −.17** −.20** −.06 .67** .45** .46** .01 .79** –
Mean/N 219 157 10.5 19.0 17.9 24.7 12.4 2.7 36.6 12.0
SD/% 86.6% 62.1% 3.8 11.9 6.2 26.7 22.0 3.7 12.8 6.2
Open in a new tab

Notes: Sex (coded as Female = 1); Marital status (coded as 1 = married/with partner); Years of education = number of years of formal education; years in the US = number of years spent in the United States; PANAS-NA = Positive and Negative Affect Schedule, Negative Affectivity Subscale; GCPS = Graded Chronic Pain Scale; Intensity = Pain Intensity Subscale; Disability = Pain-Related Disability Subscale; AUDIT-Total = Alcohol Use Disorders Identification Test, Total Score; IDAS = Inventory of Depressive and Anxiety Symptoms; Depressive = Depressive Symptoms Subscale; Anxious Arousal = Anxious Arousal Symptoms Subscale.

a

Covariates.

b

Predictor.

c

Outcome.

*

p < .05;

**

p < .01.

Pain intensity–hazardous drinking interactions

Covariates entered in the first step accounted for significant variance in depressive symptoms [F (5, 247) = 53.07, p < .001]. Marital status (β = −.12, t = −2.64, p = .009) and negative affectivity were significant univariate predictors (β = .68, t = 15.29, p < .001). In the second step, there was a significant main effect of pain intensity (β = .21, t = 4.57, p < .001), but not hazardous drinking (β = .04, t = .90, p = .368). However, as hypothesized, there was a significant interaction of pain intensity and hazardous drinking (β = .14, t = 1.97, p = .049). Examination of simple slopes revealed that the association between hazardous drinking and depressive symptoms was significant for those with higher (β = .10, t = 2.05, p = .041) but not lower (β = −.05, t = −.88, p = .381) levels of pain intensity. The JN technique indicated that hazardous drinking was significantly associated with depressive symptoms for GCPS-Intensity scores of 46.86 or higher (19.37% of the sample; see Figure 1).

Figure 1.

Figure 1.

Open in a new tab

Simple slopes for interaction of pain intensity/pain-related disability with hazardous drinking.

For anxious arousal symptoms, covariates in the first step accounted for significant variance [F (5, 247) = 46.93, p < .001]. Marital status (β = −.13, t = −2.72, p = .007), years of education (β = −.16, t = −3.38, p = .001), and negative affectivity (β = .64, t = 13.96, p < .001) were significant univariate predictors. There was a significant main effect of pain intensity (β = .24, t = 5.06, p < .001), but not hazardous drinking (β = −.03, t = −.60, p = .552). Unexpectedly, the interaction of pain intensity and hazardous drinking was not statistically significant (β = .13, t = 1.67, p = .097).

Pain-related disability–hazardous drinking interactions

Covariate results were identical to those reported above. In the second step, there was a significant main effect of pain-related disability (β = .21, t = 4.40, p < .001), but not hazardous drinking (β = .05, t = 1.16, p = .247), in predicting depressive symptoms. There was a significant interaction of pain-related disability and hazardous drinking (β = .15, t = 2.43, p = .016). Simple slope analyses revealed that the association between hazardous drinking and depressive symptoms was significant for those with higher (β = .19, t = 2.69, p = .008) but not lower (β = −.01, t = −.29, p = .773) levels of pain-related disability. Specifically, the JN found that hazardous drinking was associated with depression for GCPS-Disability scores of 14.85 or greater (24.90% of the sample).

There was a significant main effect of pain-related disability (β = .19, t = 3.86, p < .001), but not hazardous drinking (β = −.02, t = −.33, p = .744), in predicting anxious arousal symptoms. The interaction of pain-related disability and hazardous drinking was statistically significant (β = .16, t = 2.52, p = .013). Examination of simple slopes revealed that the association between hazardous drinking and anxious arousal symptoms was significant for those with higher (β = .16, t = 2.01, p = .046), but not lower (β = −.07, t = −1.61, p = .108) levels of pain-related disability. Hazardous drinking was associated with anxious arousal for those with GCPS-Disability scores of 33.02 or greater (12.65% of the sample).

Alternative models

Alternative models evaluated the interactions of anxious arousal and depression with pain intensity and pain-related disability, respectively, in relation to hazardous drinking. Covariates included sex, marital status, years of education, years in the US, and negative affectivity. There were non-significant interactions of depression and pain intensity (β = −.02, t = −.25, p = .804), anxious arousal and pain intensity (β = .01, t = .12, p = .908), depression and pain-related disability (β = −.06, t = −1.05, p = .295), and anxious arousal and pain-related disability (β = −.02, t = −.39, p = .699), in relation to hazardous drinking.

Discussion

The purpose of the present investigation was to examine the moderating role of pain severity in relations between hazardous drinking and anxiety/depression among a sample of economically disadvantaged Latinos who were recruited from a primary care medical setting. Hypotheses were largely supported. Specifically, the association between hazardous drinking and anxiety/depressive symptoms was found to be moderated by pain severity. For those with greater pain intensity, greater levels of hazardous drinking were associated with more depressive symptoms. Likewise, for those with greater pain-related disability, greater hazardous drinking was associated with more severe depressive and anxious arousal symptoms. Although the size of the effects for interactions were small (Cohen, Cohen, West, & Aiken, 2013), these moderating effects are notable (Abelson, 1985) given that a substantial portion of variance in depressive and anxiety symptoms was accounted for by covariates and main effects in the first two steps (Table 2). Indeed, interactions are commonly statistically small when evaluating change in variance explained in a model, yet consistently offer meaningful clinical insight (Rosenthal & Rubin, 1979). Interestingly, the pattern of the interaction was consistent in each case, such that associations between hazardous drinking and depressive/anxiety symptoms were conditional upon high levels of pain. Indeed, simple slope analysis revealed no significant effect of hazardous drinking on outcomes for those with low pain intensity or pain-related disability. These findings are novel and imply that associations between alcohol consumption and anxiety/depression may depend on other moderating or intervening variables.

Table 2.

Main and interactive effects of pain intensity/pain-related disability and hazardous drinking in predicting depressive and anxious arousal symptoms (n = 253).

β b t p R2 Change
Model 1: depressive symptoms (IDAS)
Step 1
 Sex −.05 −1.67 −1.01 .313
 Marital status −.12 −3.08 −2.64 .009
 Education −.10 −.34 −2.28 .023
 Years in United States −.01 −.01 −.19 .848
 Negative affectivity (PANAS-NA) .68 1.39 15.29 <.001 52***
Step 2
 Pain intensity (GCPS) .21 .10 4.57 <.001
 Hazardous drinking (AUDIT) .04 .14 .90 .368 .04***
Step 3
 Pain intensity × hazardous drinking .14 .01 1.97 .049 .01*
Model 2: anxious arousal symptoms (IDAS)
Step 1
 Sex −.05 −.97 −1.17 .242
 Marital status −.13 −1.58 −2.72 .007
 Education −.16 −.25 −3.38 .001
 Years in United States −.02 −.01 −.44 .660
 Negative affectivity (PANAS-NA) .64 .63 13.96 <.001 .49***
Step 2
 Pain intensity (GCPS) .24 .06 5.06 <.001
 Hazardous drinking (AUDIT) −.03 −.05 −.60 .552 .05***
Step 3
 Pain intensity × hazardous drinking .13 .01 1.67 .097 .01
Model 3: depressive symptoms (IDAS)
Step 2
 Pain-related disability (GCPS) .21 .12 4.40 <.001
 Hazardous drinking (AUDIT) .05 .18 1.16 .247 .04***
Step 3
 Pain-related disability × hazardous drinking .15 .03 2.43 .016 .01*
Model 4: anxious arousal symptoms (IDAS)
Step 2
 Pain-related disability (GCPS) .19 .05 3.86 <.001
 Hazardous drinking (AUDIT) −.02 −.03 −.33 .744 .03***
Step 3
 Pain-related disability × hazardous drinking .16 .01 2.52 .013 .01*
Open in a new tab

Notes: Results from step 1 are identical in models 1 and 3, and models 2 and 4, respectively; thus, they are presented in models 1 and 2 only to avoid redundancies. Standardized (β) and unstandardized (b) coefficients are presented.

*

p < .05;

**

p < .01;

***

p < .001.

Contrary to expectation, we observed no moderating effect of pain intensity in the hazardous drinking–anxious arousal association, though the effect was trending toward significance (p = .097). It is possible that other factors (e.g. discrimination, financial strain) moderate associations between hazardous drinking and anxiety symptoms, and additional research is needed to explicate other factors relating pain, hazardous drinking, and anxious arousal among Latinos.

In addition to the interactive effects described above, there were main effects of both pain intensity and pain-related disability in relation to depressive and anxious arousal symptoms, respectively. Thus, after accounting for covariates and the effect of hazardous drinking, indices of pain severity were significantly associated with anxiety/depressive outcomes. These findings contribute to a limited body of work examining pain severity and anxiety/depressive symptoms among Latinos (e.g. Garcia, 1984; Hernandez & Sachs-Ericsson, 2006; Paulus, Bakhshaie, Garza et al., 2016). However, in contrast to hypothesis, there were no main effects of hazardous drinking in relation to depressive or anxious arousal symptoms after accounting for variance explained by covariates and pain severity indices. These data suggest that hazardous drinking may not demonstrate an incremental effect above the variance accounted for by covariates and pain intensity/disability. The lack of hazardous drinking main effect (Table 2) or correlation (Table 1) with anxiety and depression was surprising given past work demonstrating such association. These findings suggest that greater attention is needed to investigate the complicated relationship that drinking may have with anxiety and depression and to identify moderators of the association (i.e. to identify for whom there is a drinking–affective connection). These current findings, in conjunction with the observed moderating effects, suggest that hazardous drinking may most usefully be examined in relation to anxiety/depression in concert with other individual difference factors such as pain experiences. Indeed, hazardous drinking was associated with anxiety/depression, but only for those with greater pain.

The findings have several clinical implications. For example, when working with anxious/depressed Latinos in primary care, there may be benefit to examining current levels of pain. Directing efforts toward Latinos in high pain may allow for preventative efforts against anxiety/depression. Accordingly, a Latino presenting with higher levels of pain and endorsing hazardous use of alcohol may benefit from tailored treatments that also address depression and anxiety. Results of the current study suggest that pain intensity (via GCPS) levels of 46.86 (i.e. moderate to severe pain intensity; Von Korff et al., 1992) or greater and pain-related disability levels of 14.85–33.02 (i.e. low to moderate pain disability) or greater may warrant clinical focus with regard to hazardous drinking and anxiety/depression. Specifically, these results suggest that although moderate to severe pain intensity may warrant clinical attention, even mild to moderate levels of pain intensity may be clinically informative. Regarding measurement of pain, the current study utilized the GCPS, which is recommended to clinicians seeking to assess pain. However, there is also a more brief (three-item) version of the GCPS (Von Korff et al., 1992) that may be more amenable in primary care settings and used for tracking pain over time. Additionally, clinicians may consider the brief PEG (pain intensity, enjoyment, and general activity) scale (Krebs et al., 2009) which may be suitable for primary care use. Yet, other studies are needed to examine clinically important ranges of pain for drinking/affective relations. Further, mood and anxiety symptoms should be carefully assessed among Latinos with concurrent pain and substance use. Future work may examine other indices of pain (e.g. chronic pain) and hazardous drinking (e.g. heavy episodic drinking) in relation to anxiety/depression among Latinos in primary care. Additionally, although this model was presented specifically among Latinos, it is possible that the model may generalize to other demographic groups and future work should investigate this interactive model more broadly.

Several limitations must be noted. First, although alternative models were tested and rejected, statistically, these data were cross-sectional, and thus preclude inferences regarding temporal precedence and causality. Furthermore, there may be bi-directional/transactional associations between variables over time (e.g. between hazardous drinking and anxiety/depression). As such, future research may examine pain and alcohol use in terms of longitudinal effects on mental health in Latinos. Second, the present Latino sample was largely female, lower income, unemployed, and seeking medical services for a wide range of health issues. Future work should evaluate the generalizability of the present model to other segments of the Latino community, including samples with more balanced gender distributions, greater variability in income/employment, and Latinos attending substance use clinics. Third, we focused on anxiety and depressive symptoms as primary dependent measures, which are among the most common mental health problems in the Latino primary care population (e.g. Potochnick & Perreira, 2010). Yet, it is possible that pain and hazardous drinking may relate to other mental health outcomes and/or culturally specific forms of distress (e.g. ataque de nervios, acculturative stress). Fourth, although individuals were given a clinical interview for psychiatric conditions, we did not thoroughly screen for medical conditions. As such, we are unable to describe the sample in terms of medical conditions and potential causes or etiology of pain. Future work should examine pain source and type of pain (e.g. neuropathic, musculoskeletal) as potential moderators of the associations demonstrated here. Finally, this study relied on self-report data and is limited by common method variance as well as potential inaccuracies in responding (e.g. due to memory, stigma, cultural biases).

Taken together, results of the current study suggest that interventions seeking to address anxiety and depressive symptoms among Latinos in primary care may benefit from consideration of both the current pain experience and hazardous drinking. This was the first study to evaluate the interplay of pain and hazardous drinking in relation to Latino mental health. Future work may benefit from developing tailored treatments for Latinos who endorse high levels of pain and hazardous drinking to offset established disparities in the experience of anxiety/depression among this understudied group.

Acknowledgements

This work has not been presented previously in any form. The study was approved by Institutional Review Board at the University of Houston. Informed written consent was obtained prior to initiating study procedures. No animals have been employed in this research.

Footnotes

Disclosure statement

No potential conflict of interest was reported by the authors.

References

  1. Abelson RP (1985). A variance explanation paradox: When a little is a lot. Psychological Bulletin, 97, 129–133. 10.1037/0033-2909.97.1.129 [DOI] [Google Scholar]
  2. Aiken LS, & West SG (1991). Multiple regression: Testing and interpreting interactions (Vol. xi). Thousand Oaks, CA: Sage. [Google Scholar]
  3. Alegría M, Canino G, Stinson FS, & Grant BF (2006). Nativity and DSM-IV psychiatric disorders among Puerto Ricans, Cuban Americans, and Non-Latino Whites in the United States: Results from the national epidemiologic survey on alcohol and related conditions. The Journal of Clinical Psychiatry, 67, 56–65. 10.4088/JCP.v67n0109 [DOI] [PubMed] [Google Scholar]
  4. Alegría M, Molina KM, & Chen C-N (2014). Neighborhood characteristics and differential risk for depressive and anxiety disorders across racial/ethnic groups in the United States. Depression and Anxiety, 31, 27–37. 10.1002/da.22197 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Alegría M, Mulvaney-Day N, Torres M, Polo A, Cao Z, & Canino G (2007). Prevalence of psychiatric disorders across Latino subgroups in the United States. American Journal of Public Health, 97, 68–75. 10.2105/AJPH.2006.087205 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Asnaani A, Richey JA, Dimaite R, Hinton DE, & Hofmann SG (2010). A cross-ethnic comparison of lifetime prevalence rates of anxiety disorders. The Journal of Nervous and Mental Disease, 198, 551–555. 10.1097/NMD.0b013e3181ea169f [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Babor TF, Higgins-Biddle JC, Saunders JB, & Monteiro MG (2001). The Alcohol Use Disorders Identification Test: Guidelines for use in primary care. Geneva: World Health Organization, Department of Mental Health and Substance Dependence. [Google Scholar]
  8. Centers for Disease Control and Prevention. (2014). Summary health statistics for U.S. adults: National Health Interview Survey 2012, Vital Health Statistics. Table 25; National data collected during 2001–2002. Hyattsville, MD: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. [Google Scholar]
  9. Chartier KG, & Caetano R (2010). Ethnicity and health disparities in alcohol research. Alcohol Research & Health, 33, 152–160. [PMC free article] [PubMed] [Google Scholar]
  10. Cintron A, & Morrison RS (2006). Pain and ethnicity in the United States: A systematic review. Journal of Palliative Medicine, 9, 1454–1473. 10.1089/jpm.2006.9.1454 [DOI] [PubMed] [Google Scholar]
  11. Cohen J, Cohen P, West SG, & Aiken LS (2013). Applied multiple regression/correlation analysis for the behavioral sciences. Routledge. Retrieved from https://books.google.com/books?hl=en&lr=&id=gkalyqTMXNEC&oi=fnd&pg=PP1&ots=tQJPZ2rc9g&sig=NslCXLQ-6j9utP1XvhHvN0HnOx4 [Google Scholar]
  12. Dawson DA, Grant BF, Stinson FS, Chou PS, Huang B, & June W (2006). Recovery from DSM-IV alcohol dependence: United States, 2001–2002. Alcohol Research & Health, 29, 131–142. [Google Scholar]
  13. Edwards RR, Moric M, Husfeldt B, Buvanendran A, & Ivankovich O (2005). Ethnic similarities and differences in the chronic pain experience: A comparison of African American, Hispanic, and White patients. Pain Medicine, 6, 88–98. 10.1111/j.1526-4637.2005.05007.x [DOI] [PubMed] [Google Scholar]
  14. Ennis SR, Rios-Vargas M, & Albert NG (2010). The Hispanic Population. Economics and Statistics Administration, US Census Bureau: US Department of Commerce. [Google Scholar]
  15. Fisher EB, Chan JCN, Nan H, Sartorius N, & Oldenburg B (2012). Co-occurrence of diabetes and depression: Conceptual considerations for an emerging global health challenge. Journal of Affective Disorders, 142, S56–S66. 10.1016/S0165-0327(12)70009-5 [DOI] [PubMed] [Google Scholar]
  16. Gagnon CM, Matsuura JT, Smith CC, & Stanos SP (2014). Ethnicity and interdisciplinary pain treatment. Pain Practice, 14, 532–540. 10.1111/papr.12102 [DOI] [PubMed] [Google Scholar]
  17. Garcia PI (1984). Stress response among physically injured Spanish-speaking/surnamed workers. Hispanic Journal of Behavioral Sciences, 6, 225–246. 10.1177/07399863840063002 [DOI] [Google Scholar]
  18. George D, & Mallery M (2003). SPSS for windows step by step: A simple study guide and reference, 11.0 update, 10/e. Boston, MA: Allyn and Bacon. [Google Scholar]
  19. Grant BF, Stinson FS, Dawson DA, Chou P, Dufour MC, Compton W, … Kaplan K (2004). 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, 61, 807–816. 10.1001/archpsyc.61.8.807 [DOI] [PubMed] [Google Scholar]
  20. Grant BF, Stinson FS, Hasin DS, Dawson DA, Patricia S, & Anderson K (2004). Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic Whites in the United States: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry, 61, 1226–1233. 10.1001/archpsyc.61.12.1226 [DOI] [PubMed] [Google Scholar]
  21. Grant JD, Vergés A, Jackson KM, Trull TJ, Sher KJ, & Bucholz KK (2012). Age and ethnic differences in the onset, persistence and recurrence of alcohol use disorder. Addiction, 107, 756–765. 10.1111/j.1360-0443.2011.03721.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim RB, … Vallerand AH (2003). The unequal burden of pain: Confronting racial and ethnic disparities in pain. Pain Medicine, 4, 277–294. [DOI] [PubMed] [Google Scholar]
  23. Hastie BA, Riley JL, & Fillingim RB (2005). Ethnic differences and responses to pain in healthy young adults. Pain Medicine, 6, 61–71. 10.1111/j.1526-4637.2005.05009.x [DOI] [PubMed] [Google Scholar]
  24. Hayes AF (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: The Guilford Press. [Google Scholar]
  25. Hernandez A, & Sachs-Ericsson N (2006). Ethnic differences in pain reports and the moderating role of depression in a community sample of Hispanic and Caucasian participants with serious health problems. Psychosomatic Medicine, 68, 121–128. 10.1097/01.psy.0000197673.29650.8e [DOI] [PubMed] [Google Scholar]
  26. Holmbeck GN (2002). Post-hoc probing of significant moderational and mediational effects in studies of pediatric populations. Journal of Pediatric Psychology, 27, 87–96. 10.1093/jpepsy/27.1.87 [DOI] [PubMed] [Google Scholar]
  27. Institute of Medicine (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC: National Academies Press. [PubMed] [Google Scholar]
  28. Krebs EE, Lorenz KA, Bair MJ, Damush TM, Wu J, Sutherland JM, … Kroenke K (2009). Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. Journal of General Internal Medicine, 24, 733–738. 10.1007/s11606-009-0981-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Lecrubier Y, Sheehan DV, Weiller E, Amorim P, Bonora I, Harnett KS, … Dunbar CG (1997). The mini international neuropsychiatric interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI. European Psychiatry, 12, 224–231. 10.1016/S0924-9338(97)83296-8 [DOI] [Google Scholar]
  30. Melkevik O, Hauge LJ, Bendtsen P, Reneflot A, Mykletun A, & Aarø LE (2016). Associations between delayed completion of high school and educational attainment and symptom levels of anxiety and depression in adulthood. BMC Psychiatry, 16. Retrieved from http://ezproxy.lib.uh.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2016-13551-001&site=ehost-live [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Morasco BJ, Gritzner S, Lewis L, Oldham R, Turk DC, & Dobscha SK (2011). Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain, 152, 488–497. 10.1016/j.pain.2010.10.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Ortega AN, Rodriguez HP, & Bustamante AV (2015). Policy dilemmas in Latino health care and implementation of the Affordable Care Act. Annual Review of Public Health, 36, 525–544. 10.1146/annurev-publhealth-031914-122421 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Paulus DJ, Bakhshaie J, Garza M, Ochoa-Perez M, Mayorga NA, Bogiaizian D, … Zvolensky MJ (2016). Pain severity and emotion dysregulation among Latinos in a community health care setting: Relations to mental health. General Hospital Psychiatry, 42, 41–48. 10.1016/j.genhosppsych.2016.07.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Paulus DJ, Bakhshaie J, Lemaire C, Garza M, Ochoa-Perez M, Valdivieso J, … Zvolensky MJ (2016). Negative affectivity and problematic alcohol use among Latinos in primary care: The role of emotion dysregulation. Journal of Dual Diagnosis, 12, 127–137. 10.1080/15504263.2016.1172897 [DOI] [PubMed] [Google Scholar]
  35. Paulus DJ, Talkovsky AM, Heggeness LF, & Norton PJ (2015). Beyond negative affectivity: A hierarchical model of global and transdiagnostic vulnerabilities for emotional disorders. Cognitive Behaviour Therapy, 44, 389–405. 10.1080/16506073.2015.1017529 [DOI] [PubMed] [Google Scholar]
  36. Potochnick SR, & Perreira KM (2010). Depression and anxiety among First-Generation immigrant latino youth: Key correlates and implications for future research. Journal of Nervous and Mental Disease, 198(7), 470–477. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Rana AQ, Qureshi ARM, Mumtaz A, Abdullah I, Jesudasan A, Hafez KK, & Rana MA (2016). Associations of pain and depression with marital status in patients diagnosed with Parkinson’s disease. Acta Neurologica Scandinavica, 133, 276–280. 10.1111/ane.12454 [DOI] [PubMed] [Google Scholar]
  38. Rosenthal R, & Rubin DB (1979). A note on percent variance explained as a measure of the importance of effects. Journal of Applied Social Psychology. Retrieved from http://psycnet.apa.org/psycinfo/1981-24869-001 [Google Scholar]
  39. Saitz R, Lepore MF, Sullivan LM, Amaro H, & Samet JH (1999). Alcohol abuse and dependence in Latinos living in the United States: validation of the CAGE (4 M) questions. Archives of Internal Medicine, 159, 718–724. [DOI] [PubMed] [Google Scholar]
  40. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, & Grant M (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction, 88, 791–804. [DOI] [PubMed] [Google Scholar]
  41. Sheehan DV, Lecrubier Y, Sheehan KH, Janavs J, Weiller E, Keskiner A, … Dunbar GC (1997). The validity of the mini international neuropsychiatric interview (MINI) according to the SCID-P and its reliability. European Psychiatry, 12, 232–241. 10.1016/S0924-9338(97)83297-X [DOI] [Google Scholar]
  42. Simon GE, Von Korff M, Piccinelli M, Fullerton C, & Ormel J (1999). An international study of the relation between somatic symptoms and depression. New England Journal of Medicine, 341, 1329–1335. 10.1056/NEJM199910283411801 [DOI] [PubMed] [Google Scholar]
  43. Stepler R, & Brown A (2016). Statistical portrait of Hispanics in the United States. Pew Research Center. Retrieved from http://www.pewhispanic.org/2016/04/19/statistical-Portrait-of-Hispanics-in-the-United-States-Key-Charts/ [Google Scholar]
  44. Substance Abuse and Mental Health Services Administration. (2013). Hispanic subgroups differ in rates of substance use treatment need and receipt. National Survey on Drug Use and Health [NSDUH] Report. Retrieved from http://www.samhsa.gov/data/sites/default/files/spot128-hispanic-treatment-2013/spot128hispanic-treatment-2013.pdf
  45. USDHHS. 2001. Mental health: Culture, race, and ethnicity: A supplement to mental health: A report of the surgeon general. Rockville (MD): U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44243/ [PubMed] [Google Scholar]
  46. Vaeth PAC, Caetano R, & Rodriguez LA (2012). The Hispanic Americans Baseline Alcohol Survey (HABLAS): The association between acculturation, birthplace and alcohol consumption across Hispanic national groups. Addictive Behaviors, 37, 1029–1037. 10.1016/j.addbeh.2012.04.015 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Vaughan EL, Robbins MJ, & Escobar OS (2014). Mental health, physical health problems, and drinking among Latino older adults. Journal of Latina/o Psychology, 2, 214–223. 10.1037/lat0000026 [DOI] [Google Scholar]
  48. Vega WA, & Lopez SR (2001). Priority issues in Latino mental health services research. Mental Health Services Research, 3, 189–200. [DOI] [PubMed] [Google Scholar]
  49. Velasco RV, Bakhshaie J, Walker RL, Viana AG, Garza M, Ochoa-Perez M, … Zvolensky MJ (2016). Synergistic effects of pain intensity and anxiety sensitivity in relation to anxiety and depressive symptoms and disorders among economically disadvantaged Latinos in a community-based primary care setting. Journal of Anxiety Disorders, 43, 23–31. 10.1016/j.janxdis.2016.07.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Von Korff M (2001). Epidemiological and survey methods: Assessment of chronic pain. In Turk DC, Melzack R, Turk DC, & Melzack R (Eds.), Handbook of pain assessment (2nd ed., pp. 603–618). New York, NY: Guilford Press. [Google Scholar]
  51. Von Korff M (2011). Assessment of chronic pain in epidemiological and health services research. Handbook of pain assessment. (3rd ed, pp. 455–473). New York, NY: Guilford Publications. [Google Scholar]
  52. Von Korff M, Ormel J, Keefe FJ, & Dworkin SF (1992). Grading the severity of chronic pain. Pain, 50, 133–149. [DOI] [PubMed] [Google Scholar]
  53. Wassertheil-Smoller S, Arredondo EM, Cai J, Castaneda SF, Choca JP, Gallo LC, … Zee PC (2014). Depression, anxiety, antidepressant use, and cardiovascular disease among Hispanic men and women of different national backgrounds: Results from the Hispanic community health study/study of Latinos. Annals of Epidemiology, 24, 822–830. 10.1016/j.annepidem.2014.09.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Watson D, Clark LA, & Tellegen A (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070. 10.1037/0022-3514.54.6.1063 [DOI] [PubMed] [Google Scholar]
  55. Watson D, O’Hara MW, Chmielewski M, McDade-Montez EA, Koffel E, Naragon K, & Stuart S (2008). Further validation of the IDAS: Evidence of convergent, discriminant, criterion, and incremental validity. Psychological Assessment, 20, 248–259. 10.1037/a0012570 [DOI] [PubMed] [Google Scholar]
  56. Watson D, O’Hara MW, Simms LJ, Kotov R, Chmielewski M, McDade-Montez EA, … Stuart S (2007). Development and validation of the Inventory of Depression and Anxiety Symptoms (IDAS). Psychological Assessment, 19, 253–268. 10.1037/1040-3590.19.3.253 [DOI] [PubMed] [Google Scholar]
  57. Zale EL, Maisto SA, & Ditre JW (2015). Interrelations between pain and alcohol: An integrative review. Clinical Psychology Review, 37, 57–71. 10.1016/j.cpr.2015.02.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Zimmerman JA, Mast BT, Miles T, & Markides KS (2009). Vascular risk and depression in the Hispanic established population for the epidemiologic study of the elderly (EPESE). International Journal of Geriatric Psychiatry, 24, 409–416. 10.1002/gps.2136 [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Zvolensky MJ, Paulus DJ, Bakhshaie J, Garza M, Ochoa-Perez M, Lemaire C, … Lejuez CW (2016). Interactive Effect of Negative Affectivity and Rumination in Terms of Mental Health Among Latinos in Primary Care. Journal of racial and ethnic health disparities, 3(4), 646–657. 10.1007/s40615-015-0183-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Zvolensky MJ, Paulus DJ, Bakhshaie J, Garza M, Ochoa-Perez M, Medvedeva A, … Schmidt NB (2016). Interactive effect of negative affectivity and anxiety sensitivity in terms of mental health among Latinos in primary care. Psychiatry Research, 243, 35–42. 10.1016/j.psychres.2016.06.006 [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES