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. Author manuscript; available in PMC: 2019 Dec 27.
Published in final edited form as: Partner Abuse. 2017;8(2):190–203. doi: 10.1891/1946-6560.8.2.190

Prevalence, Severity, and Correlates of Suicidal Ideation Among Men and Women in Batterer Intervention Programs

Caitlin Wolford-Clevenger 1, Meagan J Brem 1, Heather Zapor 1, JoAnna Elmquist 1, Gregory L Stuart 1
PMCID: PMC6934097  NIHMSID: NIHMS1062918  PMID: 31885829

Abstract

Despite the robust association found between intimate partner violence perpetration and suicidal ideation (Ilgen et al., 2009), the understanding of the development of suicidal ideation among men and women court-mandated to attend batterer intervention programs is limited. Guided by the alcohol myopia model (Josephs & Steele, 1990) and escape theory of suicide (Baumeister, 1990), this cross-sectional study examined the prevalence and severity of suicidal ideation and whether alcohol problems strengthen the relationship between depressive symptoms and suicidal ideation. Surveys were administered to 470 men and women court-mandated to attend batterer intervention programs. Results indicated that 33% of the sample experienced suicidal ideation (15% active ideation) during the 2 weeks prior to batterer intervention program entry. Moderation analyses indicated that as alcohol problems increased, the relationship between depressive symptoms and suicidal ideation strengthened. This work aids practitioners in assessing suicidal ideation in batterer intervention settings.

Keywords: intimate partner violence, perpetration, alcohol problems, alcohol myopia model, escape theory, depressive symptoms

Suicidal ideation is a significant health concern in the United States because it is an antecedent to suicide attempts and death by suicide (Centers for Disease Control and Prevention [CDC], 2013; Joiner, Walker, Rudd, & Jobes, 1999). Approximately 8.3 million men and women experienced suicidal ideation over the past year. More than 2 million of those individuals experience active suicidal ideation, a severe form of suicidal ideation involving thoughts of planning and preparing for suicide (Crosby, Han, Ortega, Parks, & Gfroerer, 2011; Joiner et al., 1999; Steer, Rissmiller, Ranieri, & Beck, 1993). Identifying the prevalence, correlates, and severity of suicidal ideation in vulnerable populations will aid in the reduction of deaths by suicide.

A population that is particularly vulnerable to suicidal ideation is men and women court-ordered to attend batterer intervention programs (BIPs) for physical, psychological, and/or sexual aggression committed against their partners (i.e., intimate partner violence [IPV]; Saltzman, Fanslow, McMahon, & Shelley, 2002). Men and women in BIPs are at particular risk for suicidal ideation because these individuals experience high rates of IPV perpetration and victimization, which have robust associations with suicidal ideation (Heru, Stuart, Rainey, Eyre, & Recupero, 2006; Ilgen et al., 2009; Nahapetyan, Orpinas, Song, & Holland, 2013; Wolford-Clevenger, Febres, et al., 2014; Wolford-Clevenger & Smith, 2014). Indeed, one study demonstrated that a high percentage (22%) of men in BIPs experience suicidal ideation during the 2 weeks prior to BIP entry (Wolford-Clevenger Febres, et al., 2014). Furthermore, nearly half of partner-violent men reported ever threatening suicide, with 25% of the threats being made the week preceding court (Conner, Cerulli, & Caine, 2002). Such suicidal ideation and threats have strong potential to lead to attempts in court-involved individuals because legal issues are independent risk factors for suicide attempts (Yen et al., 2005). Thus, identifying the correlates and severity of suicidal ideation specific to individuals in BIPs will aid the prevention of suicide in this population.

Theories regarding the causes of suicide (e.g., escape theory; Baumeister, 1990) and effects of alcohol (e.g., alcohol myopia model [AMM]; Josephs & Steele, 1990; Steele & Josephs, 1990) are useful frameworks from which to understand the trajectory to suicidal ideation in this population. Escape theory posits that cognitive deconstruction, a state of narrowed attention and emotional numbing following a stressor, limits one’s problem-solving skills and awareness of the ultimate finality of suicide, thus increasing risk for suicide attempt (Baumeister, 1990). Similarly, the AMM posits that alcohol intoxication produces a myopic effect akin to cognitive deconstruction during which attention is allocated to the most salient stimuli (Josephs & Steele, 1990; Steele & Josephs, 1990). Therefore, if negative affect is the most salient stimulus, attention will not be given to inhibitory thoughts that would reduce suicidal ideation (Giancola, Josephs, Parrott, & Duke, 2010; Hufford, 2001). There have been no direct tests of escape theory or the AMM regarding the role of alcohol problems in the development of suicidal ideation. However, the integration of the two models suggests that individuals experiencing depressive affect following a stressor (e.g., court-involvement) may abuse alcohol to numb such pain, ultimately limiting their ability to generate solutions alternative to suicide (Baumeister, 1990; Giancola et al., 2010; Hufford, 2001; Josephs & Steele, 1990; Steele & Josephs, 1990).

Empirical data suggest that consistent with escape theory and the AMM, interpersonal discord, depressed affect, and alcohol problems may converge to promote suicidal ideation among individuals in BIPs (Boenisch et al., 2010; Lamis, Leenaars, Jahn, & Lester, 2013; Yen et al., 2005). Stressful life events, particularly legal and interpersonal crises, are strongly associated with increased risk of suicidal ideation, suicide attempts, and death by suicide (Conner, Duberstein, & Conwell, 2000; Conner et al., 2012; Lamis et al., 2013; Yen et al., 2005). Being court-ordered to a BIP is one such life event that involves both legal troubles and actual or possible separation from one’s partner, thus a likely precipitant of depressed affect and suicidal ideation (Conner et al., 2002; Conner et al., 2012; Yen et al., 2005).

Alcohol problems may play a pivotal role in facilitating the trajectory to suicidal ideation among men and women attending BIPs because it is prevalent among IPV perpetrators and has been shown to increase risk for suicidal ideation, suicide attempts, and deaths by suicide, especially following interpersonal crises (Boenisch et al., 2010; Conner et al., 2012; Hayward, Zubrick, & Silburn, 1992; Miller, Teti, Lawrence, & Weiss, 2010; Stuart, Moore, Kahler, & Ramsey, 2003; Stuart, Moore, Ramsey, & Kahler, 2003). Specifically, in the context of legal and interpersonal difficulties and resulting depressive symptoms, alcohol problems may lead to frequent intoxication that restricts attentional resources and problem-solving skills, consequently exacerbating such depressive symptoms (Baumeister, 1990; Giancola et al., 2010; Hufford, 2001; Josephs & Steele, 1990; Steele & Josephs, 1990). Thus, alcohol problems may moderate the relationship between depressive symptoms and suicidal ideation in men and women in BIPs, such that as alcohol problems increase, the relationship between depressive symptoms and suicidal ideation strengthens.

In summary, the literature suggests that suicidal ideation is prevalent among partner-violent men and women; however, only one published study has reported the prevalence of suicidal ideation among men in BIPs, and no published studies have considered women (Wolford-Clevenger, Febres, et al., 2014). Additional work is needed to replicate this finding in men and women as well as to explore the percentage of individuals experiencing active ideation (i.e., planning and preparing for suicide). A culmination of previous studies suggest that in the context of the interpersonal and legal stress of being court-ordered to a BIP, depressed affect and alcohol problems may interact to increase suicidal ideation. However, no studies have directly examined this in a sample of men and women attending BIPs.

AIMS

Thus, the purpose of this study was to examine the prevalence, severity, and correlates of suicidal ideation in men and women court-ordered to attend BIPs to enhance the understanding of the development of suicide risk in this population. First, we aimed to enhance the scant empirical literature on the prevalence and severity of suicidal ideation among BIP participants by exploring the prevalence of suicidal ideation, and in particular, active suicidal ideation. Second, as posited by escape theory and the AMM, we hypothesized that alcohol problems would strengthen the relationship between depressive symptoms and suicidal ideation, while controlling for the effects of IPV (i.e., physical violence and psychological aggression) perpetration and victimization.

METHOD

Participants

A sample of 470 men (n = 391; 84.6%) and women (n = 71; 15.4%) who were court-ordered to attend BIPs in Rhode Island were recruited for a larger study. Participants’ average age was 32.91 (SD = 11.36) years old. Most of the sample identified as White/non-Hispanic (66%), followed by Hispanic/Latino (13%), African American/ non-Hispanic (9%), American Indian or Alaskan Native (3%), Asian or Pacific Islander (1%), and “other” (8%). The distribution of employment status was as follows: employed (51%), unemployed and looking for work (30%), unable to work (11%), unemployed and not actively looking for work (2%), retired (2%), student (2%), and homemaker (1%). Participants reported having, on average, 12.13 (SD = 4.11) years of education. On average, participants had two children (SD = 2.28). Participants reported, on average, 1.61 (SD = 1.67) arrests related to domestic violence, 1.27 (SD = 2.20) arrests for violence toward nonintimates, and 1.51 (SD = 2.53) nonviolent arrests. Prior to data collection, participants had attended an average of 10.68 (SD = 7.40) BIP sessions.

Procedure

An institutional review board approved this study’s procedures. Men and women who were court-ordered to attend a BIP were recruited from three BIP sites in Rhode Island. The BIP sites administered 40-hr, open enrollment, group interventions. The sites were similar in intervention content, as dictated by the Rhode Island Batterer Intervention Oversight Committee, and were psychoeducational in nature. The programs included topics such as IPV being a crime motivated by desire for power and control, perpetrators being held fully responsible for the crime, unlearning abusive behavior and replacing it with healthy communication and listening skills, reevaluating one’s beliefs that contribute to IPV, and developing empathy. BIP attendees who agreed to participate completed a battery of measures in small groups during a BIP session and were provided no compensation. Data collected were kept completely confidential.

Measures

Demographic Questionnaire

Participants reported on several demographic variables including age, gender, education, race/ethnicity, number of children, relationship length, and number of BIP sessions completed.

Intimate Partner Violence

The Revised Conflict Tactics Scale (CTS2) Physical Assault and Psychological Aggression subscales measured the frequency (0 to more than 20 times) of perpetration and victimization of psychological aggression (16 items) and physical violence (24 items) in the year prior to the BIP (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996; Straus, Hamby, & Warren, 2003). The subscale scores were computed using the sum of the midpoints of the participants’ scores on each subscale item, with higher scores indicating higher levels of physical assault and psychological aggression (Straus et al., 1996). Studies on court-mandated men have demonstrated good test–retest reliability in the CTS2 (Vega & O’Leary, 2007). This study demonstrated good internal consistencies of the Physical Violence and Psychological Aggression subscales as follows: psychological aggression perpetration (α = .82), psychological aggression victimization (α = .83), physical violence perpetration (α = .88), and physical violence victimization (α = .90).

Alcohol Problems

The Psychiatric Diagnostic Screening Questionnaire (PDSQ; Zimmerman & Mattia, 2001a, 2001b) Alcohol Abuse/Dependence Disorder subscale was used to assess alcohol problems during the 6 months prior to BIP entry. The PDSQ screens for Axis I disorders from the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The Alcohol Abuse/Dependence Disorder subscale consists of 6 yes/no items, which sums to a possible total score ranging from 0 to 6, with higher scores indicating higher levels of alcohol problems. The subscale has demonstrated good psychometric properties in psychiatric outpatients (Zimmerman & Mattia, 2001a) and demonstrated good internal consistency in the current sample (α = .81).

Depressive Symptoms

The PDSQ (Zimmerman & Mattia, 2001a, 2001b) Depression subscale measured such symptoms experienced during the 2 weeks prior to BIP entry. The sum of the 15 yes/no items that did not assess suicidal ideation constituted the Depressive Symptom scale for this study. The six suicidal ideation items of the Depression subscale were removed to create a separate suicidal ideation subscale described below. Thus, the total score ranged from 0 to 15, with higher scores indicating greater depressive symptoms. The original Depression subscale has demonstrated good psychometric properties in psychiatric outpatients (Zimmerman & Mattia, 2001a). The 15-item scale demonstrated good internal consistency in a previous sample of men in BIPs (α = .89) and in the current sample (α = .90).

Suicidal Ideation

The six suicidal ideation items of the PDSQ Depression subscale (Zimmerman & Mattia, 2001a, 2001b) were used to assess the severity of suicidal ideation over the 2 weeks prior to BIP entry. This subscale also consisted of yes/ no items, which totaled to a score ranging from 0 to 6. Although this is not a validated measure of suicidal ideation, the item content is consistent with recent conceptualizations of suicidal ideation, containing items that assess wishes for death/ suicide and serious planning/preparation for suicide (Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007). Observations of the item content demonstrated that four items assessed passive suicidal ideation and two assessed active suicidal ideation.

The subscale demonstrated good internal consistency in the current sample (α = .88), as in a previous sample of men attending BIPs (α = .88).

RESULTS

Means and standard deviations for the variables were computed and are displayed in Table 1. The suicidal ideation, depressive symptom, alcohol problems, and IPV subscales demonstrated positive skew and kurtosis; therefore, these variables were log-transformed for correlational and regression analyses. The results from the analyses using the log-transformed variables did not differ from results of analyses using the original variables; therefore, for clarity, we report the results using the original variables. To examine the prevalence of suicidal ideation, the suicidal ideation subscale was dichotomized into 0 = absent and 1 = present. The same procedure was done for the total of the four passive suicidal ideation items and the two active suicidal ideation items. Thirty-three percent of the sample reported experiencing some level of suicidal ideation during the 2 weeks prior to entering the BIP, with 15% experiencing active suicidal ideation. Men and women did not differ in prevalence of suicidal ideation χ2(1, N = 419) = 0.01, p = .942.

TABLE 1.

Bivariate Correlations and Descriptive Statistics for Study Measures

1 2 3 4 5 6 7 8
1. Suicidal ideation —
2. Psychological aggression perpetration .12* —
3. Physical violence perpetration .14** .63** —
4. Psychological aggression victimization .13* .87** .57** —
5. Physical violence victimization .15** .60** .73** .71** —
6. Alcohol problems .40** .28** .23** .24** .19** —
7. Depressive symptoms .58** .28** .23** .27** .27** .55** —
8. Number of BIP sessions −.09 .00 .02 .02 .00 −.09 −.04 —
M 0.98 38.10 11.62 43.82 20.01 1.44 4.82 10.68
(SD) 1.76 37.95 27.33 42.44 37.95 1.77 4.20 7.40
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Note. BIP = batterer intervention program.

*

p < .05.

**

p < .01.

Prior to testing our hypothesis that alcohol problems would strengthen the relationship between depressive symptoms and suicidal ideation, Spearman’s rho correlations were computed using the continuous variables of suicidal ideation, depressive symptoms, alcohol problems, physical violence, psychological aggression, and number of BIP session attended because most variables were on an ordinal scale (see Table 1 for correlations). Depressive symptoms, alcohol problems, physical violence, and psychological aggression, but not number of BIP sessions, were each positively correlated with suicidal ideation, supporting their inclusion in the multivariate analysis.

We proceeded to test the hypothesis that alcohol problems would moderate the relationship between depressive symptoms and suicidal ideation while controlling for IPV perpetration and victimization. To test this hypothesis, we used Hayes and Matthes’ (2009) SPSS macro for testing moderation in ordinary least squares regression. The continuous suicidal ideation variable was entered as the criterion variable, the Depressive Symptom subscale as the focal predictor, and the Alcohol Problems subscale as the moderating variable. The Physical Violence and Psychological Aggression Perpetration and Victimization subscales were entered as covariates. Variables were mean centered for the analysis.

The overall model fit was significant, explaining 39% of the variance in suicidal ideation, R2 = .39, F(7, 316) = 29.06, p < .001. Depressive symptoms and alcohol problems, but not any of the IPV victimization or perpetration variables, contributed significant variance to suicidal ideation. The interaction term was significant, contributing a significant increase in variance (R2 change = .02, F = 10.05, p = .002; see Table 2 for regression results). The interaction was probed at the mean, and 1 SD above and below the mean of alcohol problems, which demonstrated that as alcohol problems increased, the relationship between depressive symptoms and suicidal ideation strengthened. That is, depressive symptoms were positively associated with suicidal ideation at low (B = 0.14, p < .001), average (B = 0.20, p < .001), and high levels of alcohol problems (B = 0.26, p < .001). See Figure 1 for a visual depiction of the interaction.

TABLE 2.

Results of Regression Predicting Suicidal Ideation

Variable B t p
Psychological aggression perpetration −0.0030 −0.82 .41
Psychological aggression victimization 0.0010 0.39 .77
Physical violence perpetration −0.0010 −0.27 .79
Physical violence victimization −0.0001 −0.02 .98
Depressive symptoms 0.2000 9.19 .001
Alcohol problems 0.1200 2.30 .02
Depressive Symptoms × Alcohol Problems 0.0300 3.17 .002
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Figure 1.

Figure 1.

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The moderating effect of alcohol problems on the relationship between depressive symptoms and suicidal ideation.

DISCUSSION

This study is among the first to examine the prevalence, severity, and correlates of suicidal ideation in a sample of men and women attending BIPs. Thirty-three percent of the sample reported having experienced suicidal ideation during the 2 weeks prior to attending the BIP, with 18% experiencing passive ideation and 15% experiencing active ideation. IPV perpetration, victimization, alcohol problems, and depressive symptoms were correlated with suicidal ideation. However, only depressive symptoms and alcohol problems were associated with suicidal ideation in the multivariate model, and as hypothesized interacted such that as alcohol problems increased, the relationship between depressive symptoms and suicidal ideation intensified.

The prevalence of suicidal ideation demonstrated in this study is consistent with theoretical assertions that negative life events—particularly those involving legal and interpersonal problems—increase acute suicide risk (Baumeister, 1990; Conner, Duberstein, Conwell, & Caine, 2003). These findings also corroborate past work highlighting the prevalence of suicidal ideation among men and women attending BIPs (Wolford-Clevenger et al., 2014) and extends the literature, demonstrating that 15% of the sample experienced active ideation, involving planning and preparing for a suicide attempt. The number of individuals engaging in active suicidal ideation in this study (15%) is larger than that of epidemiological reports (1%; CDC, 2013), which may be because of the high rates of psychopathology (Stuart, Moore, Gordon, Ramsey, & Kahler, 2006) and suicide attempts in IPV perpetrators (Conner et al., 2002). Such a high prevalence of a severe form of suicidal ideation is concerning because it indicates greater risk for suicide attempt, especially when experienced by an individual with previous suicide attempts (Joiner & Rudd, 2000). Furthermore, suicidal ideation involving serious planning and preparation may also indicate increased risk of harm to the perpetrator’s partner because suicidal ideation is a risk factor for intimate partner homicide (Koziol-McLain et al., 2006). The high prevalence and potential consequences of suicidal ideation in this population signify a need for routine suicide risk assessment in BIPs.

The bivariate positive associations of suicidal ideation with IPV perpetration, victimization, alcohol problems, and depressive symptoms support past work in clinical, forensic, and college student samples (Heru et al., 2006; Ilgen et al., 2009; Lamis et al., 2013; Nahapetyan et al., 2013; Wolford-Clevenger et al., 2014). However, in a multivariate analysis, depressive symptoms and alcohol problems emerged as the sole, unique correlates of suicidal ideation and interacted such that increases in alcohol problems strengthened the relationship between depressive symptoms and suicidal ideation. This finding supports an integrated model of escape theory and the AMM that suggests that in the context of a negative life event, alcohol problems (which presumably increase frequency of intoxication) may narrow attention to painful affect, decrease inhibition and problem-solving abilities, and thereby increase suicidal ideation (Baumeister, 1990; Giancola et al., 2010; Hufford, 2001; Josephs & Steele, 1990; Steele & Josephs, 1990). Although this is the first direct test of the moderating effect of alcohol problems on the relationship between depressive symptoms and suicidal ideation, future work is needed to improve on this study’s limitations and confirm and elaborate on this relationship.

Limitations and Future Research Implications

The limitations and findings of this study suggest avenues for future research. First, this study assessed suicidal ideation using suicide-related items from a scale designed to assess depressive symptoms. Although the content of the items is consistent with conceptualizations (Silverman et al., 2007) and other measures of suicidal ideation, future work should employ the use of well-validated suicidal ideation scales. Second, we used cross-sectional, retrospective, survey measures of all study variables, including measuring suicidal ideation occurring 2 weeks prior to BIP entry. Although we believe this time period still captures a time when perpetrators are experiencing legal and interpersonal stress, future studies should be designed to most accurately capture perpetrators’ experiences.

Longitudinal studies, particularly using daily diary methods, are ideal to reduce recall bias and establish temporal order, which would provide a better test of escape theory and the AMM. Third, we did not directly assess individuals’ perceived stress in relation to potential interpersonal loss and legal issues. Assessing for these perceptions will provide a more direct test of escape theory. Fourth, each study variable was measured using the PDSQ. Replications using various measures of these constructs would advance these findings. Fifth, future work should measure history of suicide attempts, particularly proximal to BIP entry because distinguishing risk factors for suicidal ideation from suicide attempts is critical for effective suicide risk assessment.

Finally, the development of suicide risk among partner-violent men and women attending BIPs is severely understudied and requires additional theoretical and empirical work to advance our understanding and prevention of suicide and related homicide deaths in this population (Koziol-McLain et al., 2006). The AMM and escape theory are two models of many that may aid the understanding and prevention of suicide risk in IPV perpetrators. Empirical tests of these theories and other related models (e.g., reactive aggression theory of suicide; Conner et al., 2003) are imperative to refine our conceptualization and prevention of this problem.

Clinical Implications

Given that one out of three perpetrators endorsed experiencing suicidal ideation prior to BIP entry in this study, suicidal ideation should be assessed at BIP outset. The current structure of most BIPs does not include individualized, routine suicide risk assessments (Juodis, Starzomski, Porter, & Woodworth, 2014). Most BIPs employ a blend of cognitive behavioral and feminist-based methods for reducing violence risk, with little focus on perpetrators’ individual needs, such as suicidal ideation (Juodis et al., 2014; Stuart, Temple, & Moore, 2007). This is unfortunate because many studies have demonstrated that the severity of IPV, motivations for IPV, and severity of mental health problems vary considerably among IPV perpetrators (Elmquist et al., 2014; Holtzworth-Munroe & Stuart, 1994; Langhinrichsen-Rohling, McCullars, & Misra, 2012; Stuart et al., 2006). Therefore, the need for individualized suicide risk assessment falls within the general needs for individualized needs assessment in BIPs. Understandably, time and resource demands make suicide risk assessment and management in BIPs difficult. However, brief screeners at intake could be used to identify individuals in need of further assessment and referral to individual psychotherapy, relevant adjunct treatments, and emergency care (Joiner et al., 1999).

If screeners identify a need for further assessment, acute risk (i.e., active suicidal ideation) and chronic risk (i.e., multiple suicide attempts) should be considered in suicide risk assessment (Joiner et al., 1999). The high prevalence of active suicidal ideation (15%) observed in this study suggests that several perpetrators in BIPs may meet criteria for acute risk. Chronic risk for suicide could be approximately measured through suicide threat or attempt items on homicide risk scales (e.g., Danger Assessment; Campbell, Glass, Sharps, Laughon, & Bloom, 2007). However, providers must differentiate threats from attempts because perpetrators often use suicidal threats to control their partners (Dutton & Goodman, 2005). Furthermore, the presence of suicidal ideation may necessitate the assessment of homicide risk and appropriate communication of such risk to the perpetrators’ victims.

Finally, the current findings support the implementation of assessment and treatment of perpetrators’ alcohol problems and depressive symptoms in BIPs to reduce violence, including suicide. No known studies tested the effectiveness of adjunct treatments for alcohol abuse and depressive symptoms on suicide risk in BIPs; however, implementing treatments for depression may reduce suicidal ideation. Future treatment studies assessing the effectiveness of mental health and alcohol abuse interventions on IPV should aim to include outcome measures on suicidal ideation and attempts because it will inform suicide prevention efforts.

CONCLUSION

This study aimed to advance the underdeveloped understanding of the prevalence and correlates of suicidal ideation among partner-violent men and women attending BIPs by providing a preliminary test of an integrated model of escape theory and the AMM (Baumeister, 1990; Steele & Josephs, 1990). Results supported the predictions of escape theory and AMM, demonstrating a high prevalence of suicidal ideation and that alcohol problems strengthened the relationship between depressive symptoms and suicidal ideation. These findings suggest that future research is imperative to refine our understanding and prevention of suicide-related thoughts and behaviors in batterer intervention settings.

Acknowledgments

This work was supported, in part, by grant K24AA019707 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) awarded to the last author. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAAA or the National Institutes of Health.

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