Distal and proximal factors related to aggression severity among patients in substance abuse treatment: family history, alcohol use and expectancies

Daily patterns of substance use and violence among a high-risk urban emerging adult sample: Results from the Flint Youth Injury Study

OBJECTIVE

Interpersonal violence is a significant public health problem, with substance use a key risk factor. Intensive longitudinal methods (ILMs) provide data on daily patterns/relationships between substance use and violence, informing prevention. Prior daily research has not focused on these relationships among urban minority samples.

METHODS

Within an RCT comparing ILM assessment/schedule methods, 162-participants completed daily IVR (n = 81) or SMS (n = 81) assessments measuring 19 substance use and violence (partner/non-partner) behaviors daily for 90-days. GLMMs characterized between- and within-person predictors of daily violence.

RESULTS

Participants [48.7%-female; age = 24.4; 62.3%-African-American; 66.7%-public assistance] completed an average of 46.5 daily reports [SD = 26.7]. Across 90-days, alcohol was characterized by episodic weekend use (average = 10 days-of-use, 34.4% drinking-days involved binge-drinking), while marijuana use was continuous (average = 27 days-of-use; 1.7 times/day), with no weekend differences. Among 118-violent conflicts, 52.5% occurred on weekends; 57.6% were with non-partners/peers; 61.0% involved perpetration/57.6% victimization; and 52.5% involved severe violence. For violence conflicts, 27.1% were preceded by alcohol/22.9% preceded by drug use. Between-person predictors of daily violence included retaliatory attitudes (AOR = 3.2) and anxiety (AOR = 1.1). Within-person predictors included weekends (AOR = 1.6), binge drinking (AOR = 1.9), non-medical prescription opioid use (AOR = 3.5) and illicit drug use (AOR = 8.1).

CONCLUSION

Among a high-risk urban minority sample, we found that higher baseline retaliatory attitudes and anxiety, as well as same-day binge drinking, non-medical prescription opioid use, and illicit drug use were associated with daily violence, likely reflecting both pharmacological and socio-contextual factors. Addressing substance use and retaliatory violence with tailored prevention efforts may aid in decreasing negative interpersonal violence outcomes.

Tracking Assault-injured, Drug-using Youth in Longitudinal Research: Follow-up Methods

OBJECTIVES

Violence is one of the leading causes of death among youth ages 14 to 24. Hospital- and emergency department (ED)-based violence prevention programs are increasingly becoming a critical part of public health efforts; however, evaluation of prevention efforts is needed to create evidence-based best practices. Retention of study participants is key to evaluations, although little literature exists regarding optimizing follow-up methods for violently injured youth. This study aims to describe the methods for retention in youth violence studies and the characteristics of hard-to-reach participants.

METHODS

The Flint Youth Injury (FYI) Study is a prospective study following a cohort of assault-injured, drug-using youth recruited in an urban ED, and a comparison population of drug-using youth seeking medical or non-violence-related injury care. Validated survey instruments were administered at baseline and four follow-up time points (6, 12, 18, and 24 months). Follow-up contacts used a variety of strategies and all attempts were coded by type and level of success. Regression analysis was used to predict contact difficulty and follow-up interview completion at 24 months.

RESULTS

A total of 599 patients (ages 14-24) were recruited from the ED (mean ± SD age = 20.1 ± 2.4 years, 41.2% female, 58.2% African American), with follow-up rates at 6, 12, 18, and 24 months of 85.3%, 83.7% 84.2%, and 85.3%, respectively. Participant contact efforts ranged from two to 53 times per follow-up time frame to complete a follow-up appointment, and more than 20% of appointments were completed off site at community locations (e.g., participants' homes, jail/prison). Participants who were younger (p < 0.05) and female (p < 0.01) were more likely to complete their 24-month follow-up interview. Participants who sought care in the ED for assault injury (p < 0.05) and had a substance use disorder (p < 0.01) at baseline required fewer contact attempts to complete their 24-month follow-up, while participants reporting a fight within the immediate 3 months before their 24-month follow-up (p < 0.01) required more intensive contact efforts.

CONCLUSIONS

The FYI study demonstrated that achieving high follow-up rates for a difficult-to-track, violently-injured ED population is feasible through the use of established contact strategies and a variety of interview locations. Results have implications for follow-up strategies planned as part of other violence prevention studies.

Child Maltreatment and Physical Victimization: Does Heavy Drinking Mediate the Relationship?

Past studies examining the child maltreatment (CM)/victimization pathway have been limited by their focus on sexual victimization, narrow windows of assessment, and failure to examine gender differences. In the current study, we sought to examine (1) the impact of CM on physical victimization (PV) trajectories from adolescence to young adulthood and (2) the extent to which heavy drinking mediated the relationship between CM and later PV. Using three waves of the National Longitudinal Study of Adolescent to Adult Health, we found that CM was associated with a 69% greater odds of later PV for both genders, after the inclusion of control variables, and that the risk continued into adulthood. Further, heavy drinking was found to mediate the CM/victimization pathway at Wave I, but not at later waves. When mediation was examined separately for men and women, support for mediation was found for men and women. The current study suggests that CM represents a liability for interpersonal violence for both genders and highlights the importance of looking at victimization across time.

Developing an Integrated Violence Prevention for Men and Women in Treatment for Substance Use Disorders

Rates of past-year partner and non-partner violence perpetration (VP) in substance use disorder (SUD) treatment samples exceed 50%, with studies showing rates of past-year VP exceeding 70% when considering violence occurring with either intimate partners or non-partners. However, SUD treatment programs typically do not include VP prevention interventions, and the few studies examining the impact of SUD interventions on VP have focused exclusively on partner VP. This study summarizes results of a randomized controlled pilot study of an Integrated Violence Prevention Treatment (IVPT) designed to address VP across partner and non-partner relationships as well as predictors of post-treatment VP. Participants were men (70%) and women (30%) in SUD treatment reporting past-year VP who were randomized to either IVPT or a control condition. The IVPT involved a Motivational Interviewing session targeting interpersonal conflicts, followed by five cognitive-behavioral therapy sessions focusing on VP prevention skills. The control condition included a session including a videotape and discussion of anger management, followed by five psycho-educational sessions common for SUD settings. Results showed that VP (total, partner, and non-partner) and cocaine use significantly decreased between baseline and 3-month follow-up for both conditions, and the IVPT group showed a significant decline in alcohol use. Analyses focusing on VP during follow-up revealed that baseline cocaine use and drinking during the follow-up predicted post-treatment VP. Together, these findings suggest that IVPT is a promising intervention (feasible, appears to impact drinking, an important factor related to violence) but that additional continuing care approaches may be indicated to sustain positive outcomes.

Daily Associations Between Alcohol Consumption and Dating Violence Perpetration Among Men and Women: Effects of Self-Regulation

OBJECTIVE

Alcohol intoxication has been associated with dating violence perpetration, defined here as psychological and/or physical violence occurring between young adult dating partners. However, little is known about how the individual variability in the level of alcohol intoxication would influence dating violence perpetration and how sex and self-regulation might influence this association.

METHOD

College-aged men and women (N = 146) from a large southwestern U.S. university completed background questionnaires, including the Brief Self-Control Scale, to assess self-regulation and then reported their dating violence perpetration and alcohol consumption using a 90-day Timeline Followback assessment. Their average estimated blood alcohol concentration (eBAC) and their daily deviation from this average were calculated for each of the 90 days to examine the between- and within-person effects of alcohol consumption, respectively.

RESULTS

Results of a two-level generalized estimating equation suggest that increases in daily eBAC were associated with an increased likelihood of perpetrating dating violence; however, this association was stronger for those who had a low average eBAC compared with those who had a high average eBAC. For those who had a low average eBAC, higher self-regulation was associated with a lower probability of perpetrating dating violence, whereas among those with a high average eBAC, self-regulation was not associated with dating violence perpetration. Sex did not moderate the association between eBAC and dating violence perpetration.

CONCLUSIONS

Findings highlight the importance of self-regulation in dating violence perpetration-particularly for those with low average eBACs-and the need for varied intervention strategies, depending on one's typical drinking pattern.

Alcohol-induced blackouts and maternal family history of problematic alcohol use

BACKGROUND

Consequences of heavy drinking include alcohol-induced blackouts, which are periods of amnesia for all or part of a drinking event. One risk factor for blackouts is family history of problematic alcohol use (FH+); however, research rarely distinguishes maternal from paternal FH+. The objective of this study was to examine whether maternal or paternal FH+ better predicts likelihood of experiencing blackouts than a general measure of overall FH+, and whether gender moderates this association.

METHOD

Participants (N=1164; 65.4% are female) were first-time college freshmen (age range=17-19) who participated in a 6-year, 10-assessment, longitudinal study in the United States. Alcohol-induced blackouts, the dependent measure, were dichotomized (yes/no) based on endorsement of memory problems after drinking using a single item during Years 4-6. FH+, captured at baseline, was coded if participants self-reported that their mother, father, or any of their four grandparents were a possible or definite problem drinker.

RESULTS

Overall, 773 (66.4%) participants reported experiencing blackouts during Years 4-6. Women were more likely to report blackouts than men; however, compared with women with a maternal FH+, men with a maternal FH+ were more than twice as likely to report blackouts.

DISCUSSION

Men appear to be more susceptible than women to the effects of a maternal FH+. Genetic and environmental explanations for this finding are discussed. In sum, these findings are an important step toward understanding a significant yet understudied negative consequence of heavy alcohol use.

The Effect of Neighborhood Context on the Relationship Between Substance Misuse and Weapons Aggression in Urban Adolescents Seeking ED Care

BACKGROUND

Frameworks for studying the ecology of human behavior suggest that multiple levels of the environment influence behavior and that these levels interact. Applied to studies of weapons aggression, this suggests proximal risk factor (e.g., substance use) effects may differ across neighborhoods.

OBJECTIVES

To estimate how the association between weapons aggression and substance use varies as a function of several community-level variables.

METHODS

Individual-level measures (demographics, behavioral measures) were obtained from a survey of youth aged 14-24 years old seeking care at a Level-1 ED in Flint, Michigan. Community-level variables were obtained from public sources. Logistic generalized additive models were used to test whether community-level variables (crime rates, alcohol outlets, demographics) modify the link between individual-level substance use variables and the primary outcome measure: self-reported past 6-month weapon (firearm/knife) related aggression.

RESULTS

The effect of marijuana misuse on weapons aggression varied significantly as a function of five community-level variables: racial composition, vacant housing rates, female headed household rates, density of package alcohol outlets, and nearby drug crime rates. The effect of high-risk alcohol use did not depend on any of the eight community variables tested.

CONCLUSIONS

The relationship between marijuana misuse and weapons aggression differed across neighborhoods with generally less association in more disadvantaged neighborhoods, while high-risk alcohol use showed a consistently high association with weapons aggression that did not vary across neighborhoods. The results aid in understanding the contributions of alcohol and marijuana use to the etiology of weapon-related aggression among urban youth, but further study in the general population is required.

Substance use and violence among youth: a daily calendar analysis

BACKGROUND

While researchers have identified factors that contribute to youth violence, less is known about the details of violent incidents. In addition, substance use has been linked to youth violence; however, little is known about actual substance use on days in which violence occurs.

OBJECTIVE

This study examined reasons for peer violence and the association between substance use and violence using daily calendar-based analyses among at-risk urban youth.

METHODS

Data were collected from Emergency Department (ED) patients (ages 14-24; n = 599; 59% male, 65% African American) who screened positive for substance use in the past 6 months. Daily data regarding past 30-day substance use and violence and reasons for violent incidents were obtained via semi-structured interviews. Multi-level multinomial regression models were conducted to test the associations between substance use and peer violence incidents (i.e., none, moderate and severe).

RESULTS

Conflict over 'personal belongings' was a common reason for violence among males; 'jealousy'/'rumors' were common reasons among females. Moderate victimization was more likely to be reported on days in which participants reported alcohol and cocaine use. Severe victimization was more likely to be reported on days in which participants reported alcohol use. Moderate or severe aggression was more likely to be reported on days in which participants reported alcohol and non-medical sedative use.

CONCLUSIONS

RESULTS suggest that youth violence prevention that addresses differential reasons for violence among males and females as well as substance use would be beneficial.

Distal and proximal factors associated with aggression towards partners and non-partners among patients in substance abuse treatment

Studies of violence in substance use disorder (SUD) treatment settings typically focus on partner aggression (PA) although non-partner aggression (NPA) is also a common problem. This study examines potentially distinct paths of distal and proximal risk factors related to aggression towards non-partners (NPA) and partners (PA) among a SUD treatment sample. The sample included 176 adults reporting past-year violence. Bivariate analyses indicated several distal and proximal factors were associated with NPA and PA. According to multivariate, multiple mediation analyses youth aggression history was a factor for both NPA and PA. Alcohol and cocaine use and psychological distress were associated with NPA; marijuana use was associated with PA. There also was evidence of indirect effects of distal factors on NPA and PA. The results suggest that there may be substantially different dynamics associated with NPA and PA, and have implications for developing screening, assessment and treatment protocols targeting violence among individuals in SUD treatment.

Characteristics of youth seeking emergency care for assault injuries

OBJECTIVE

To characterize youth seeking care for assault injuries, the context of violence, and previous emergency department (ED) service utilization to inform ED-based injury prevention.

METHODS

A consecutive sample of youth (14-24) presenting to an urban ED with an assault injury completed a survey of partner violence, gun/knife victimization, gang membership, and context of the fight.

RESULTS

A total of 925 youth entered the ED with an assault injury; 718 completed the survey (15.4% refused); 730 comparison youth were sampled. The fights leading to the ED visit occurred at home (37.6%) or on streets (30.4%), and were commonly with a known person (68.3%). Fights were caused by issues of territory (23.3%) and retaliation (8.9%); 20.8% of youth reported substance use before the fight. The assault-injured group reported more peer/partner violence and more gun experiences. Assault-injured youth reported higher past ED utilization for assault (odds ratio [OR]: 2.16) or mental health reasons (OR: 7.98). Regression analysis found the assault-injured youth had more frequent weapon use (OR: 1.25) and substance misuse (OR: 1.41).

CONCLUSIONS

Assault-injured youth seeking ED care report higher levels of previous violence, weapon experience, and substance use compared with a comparison group seeking care for other complaints. Almost 10% of assault-injured youth had another fight-related ED visit in the previous year, and ~5% had an ED visit for mental health. Most fights were with people known to them and for well-defined reasons, and were therefore likely preventable. The ED is a critical time to interact with youth to prevent future morbidity.

Event-level analysis of antecedents for youth violence: comparison of dating violence with non-dating violence

BACKGROUND

Dating violence (DV) has emerged as a major concern among youth with links to substance use, injuries, and death. The emergency department (ED) provides an opportunity for violence screening and prevention interventions. Additional data are needed regarding antecedents of DV versus non-dating violence (NDV; e.g., acquaintance, stranger) to develop ED-based violence interventions for youth.

METHODS

Participants were 575 patients screening positive for past 6-month drug use in an urban ED who completed timeline follow-back aggression modules at baseline and 6- and 12-months, indicating event-specific antecedents of violence. Multi-level logistic regressions using event-level data, nested by individual and time (i.e. baseline, 6- and 12-month assessment intervals), were used to examine antecedents of DV vs. NDV. Post-hoc analyses examined substance use×reasons and gender interactions.

RESULTS

Prescription sedative/opioid misuse was more likely to be reported prior to DV whereas alcohol only, and co-ingested alcohol and marijuana only, were more likely to be reported prior to NDV. Reasons for DV included: "personal belongings", "angry/bad mood," "jealousy," "drunk/high on drugs" and "arguing about sex". Reasons for NDV included: "rumors," "retaliation," "personal space" and "aid (someone) due to physical attack". Substance use before/during conflicts and reasons for conflicts were both uniquely associated with DV versus NDV. Two gender interactions were found.

CONCLUSIONS

ED based interventions for urban youth need to be tailored by gender, substance use (alcohol, cocaine, sedatives), reasons for violence, and type of violence (DV vs. NDV).

Firearm possession among adolescents presenting to an urban emergency department for assault

BACKGROUND AND OBJECTIVES

Firearm violence is a leading cause of death among youth. The objectives of this study were (1) determine firearm possession rates and associated correlates among youth seeking care for assault in an emergency department (ED); (2) understand differences in risk factors for youth with firearm possession; and (3) identify firearm possession characteristics in this population: type, reason for possession, and source of firearms.

METHODS

Youth (14 to 24 years old) presenting to a Level 1 ED with assault were administered a computerized screening survey. Validated instruments were administered, measuring demographics, firearm rates and characteristics, attitudes toward aggression, substance use, and previous violence history.

RESULTS

Among 689 assault-injured youth, 23% reported firearm possession in the past 6 months. Only 17% of those reporting firearm possession obtained the gun from a legal source; 22% reported ownership of highly lethal automatic/semiautomatic weapons and 37.1% reported having a firearm for protection. Logistic regression analysis identified significant correlates of firearm possession, including male gender, higher socioeconomic status, illicit drug use, recent serious fight, and retaliatory attitudes.

CONCLUSIONS

ED assault-injured youth had high rates of firearm possession (23.1%), most of which were not obtained from legal sources. Youth with firearm possession were more likely to have been in a recent serious fight, and to endorse aggressive attitudes that increase their risk for retaliatory violence. Future prevention efforts should focus on minimizing illegal firearm access among high-risk youth, nonviolent alternatives to retaliatory violence, and substance use prevention.

A daily calendar analysis of substance use and dating violence among high risk urban youth

BACKGROUND

Dating violence (DV) among youth is an important public health problem. This study examined reasons for physical DV and the association between substance use and youth DV using daily calendar-based analyses among at-risk urban youth.

METHODS

Patients (aged 14-24) presenting to an urban Emergency Department (ED) for a violent injury and a proportionally selected comparison sample of non-violently injured youth who screened positive for substance use in the past 6 months (n=599) were enrolled in this study. Multi-level, multinomial regressions were conducted using daily-level substance use data from Time Line Follow Back (TLFB) responses and physical DV data that were obtained by coding Time Line Follow Back - Aggression Module responses for the 30 days prior to visiting the ED.

RESULTS

The two most commonly reported reasons for physical dating aggression and victimization, across sexes, were "jealousy/rumors" or "angry/bad mood." Multi-level multinomial regression models, adjusting for clustering within individual participants, showed that among females, cocaine use and sedative/opiate use were associated with severe dating victimization and alcohol use was associated with severe dating aggression.

CONCLUSIONS

Use of TLFB data offers a unique opportunity to understand daily-level factors associated with specific incidents of DV in more detail. This study provides novel data regarding reasons for DV and the relationship between daily substance use and DV among urban youth, with alcohol, cocaine, and sedative/opiate use being associated with various types of DV. ED based DV interventions should be tailored to address youths' reasons for DV as well as reducing their substance use.

Violence among men and women in substance use disorder treatment: a multi-level event-based analysis

BACKGROUND

This study examined associations between acute alcohol and drug use and violence towards others in conflict incidents (overall, partner, and non-partner conflict incidents) by men and women recruited from substance use disorder (SUD) treatment.

METHODS

Semi-structured interviews were used to obtain details about interpersonal conflict incidents (substance use, whether specific conflicts were with intimate partners or non-partners) in the 180 days pre-treatment. Participants for this study were selected for screening positive for past-year violence (N=160; 77% men, 23% women).

RESULTS

Multi-level multinomial regression models showed that after adjusting for clustering within individual participants, the most consistent predictors of violence across models were acute cocaine use (significant for overall, intimate partner and non-partner models), acute heavy alcohol use (significant for overall and non-partner models), and male gender (significant in all models).

CONCLUSIONS

This study was the first to explicitly examine the role of acute alcohol and drug use across overall, partner and non-partner conflict incidents. Consistent with prior studies using a variety of methodologies, alcohol, cocaine use and male gender was most consistently and positively related to violence severity (e.g., resulting in injury). The results provide important and novel event-level information regarding the relationship between acute alcohol and specific drug use and the severity of violence in interpersonal conflict incidents.

Correlates of intimate partner violence among men and women in an inner city emergency department

The current study surveyed medical or injured patients (men and women) in an inner city emergency department to examine the rates and correlates of intimate partner violence, including substance use patterns. Over a 2-year period, participants (n = 10,744) self-administered a computerized health survey during their emergency department visit that included screening items regarding past year history of intimate partner violence (including victimization and aggression). Overall, rates of any intimate partner violence involvement in past year were 8.7% (7.3% victimization and 4.4% aggression); however, women were more likely than men to report intimate partner violence. When examining participants' substance use patterns, participants who reported using both alcohol and cocaine were most likely to report intimate partner violence. Predictors of partner aggression and victimization were remarkably similar. This article provides unique data regarding correlates of past year intimate partner violence history among a comprehensive sample of male and female emergency department patients presenting for medical complaints or injury.

Prevalence of past year assault among inner-city emergency department patients

STUDY OBJECTIVE

We determine the rates of past year nonpartner violent assault, both victimization and aggression, and assess variables associated with nonpartner violent assault, particularly with regard to substance use.

METHODS

A cross-sectional computerized standardized survey study was conducted to assess nonpartner violent assault, physical and mental health, and substance use among patients presenting to an inner-city ED during 2 years. Patients (aged 19 to 60 years) with normal vital signs in an urban emergency department (ED) from 9 am to 11 pm were eligible; pregnant patients and those with a chief complaint of psychiatric evaluation were excluded. Logistic regression analyses were conducted to predict any nonpartner violent assault.

RESULTS

Ten thousand seven hundred forty-four patients were enrolled (80% response rate); 14% of the sample reported any past year nonpartner violent assault (9% perpetration; 11% victimization). Findings from regression analyses found that participants with any past year nonpartner violent assault (victimization or aggression) were more likely than their counterparts to be men (2.2), to be single (1.5), to be unemployed (1.1), to present to the ED for injury (1.9), and to report poor physical health (1.3) or poor mental health (1.9). They were less likely to be black (0.8), or older (0.95). Alcohol use (1.7), marijuana use (2.4), cocaine use (3.1), prescription drug use (1.4), and past treatment (1.7) were associated with experiencing past year nonpartner violent assault.

CONCLUSION

Fourteen percent of patients seeking care in this inner-city ED experience violence with a nonpartner. Substance use-specifically cocaine-was the strongest predictor of any nonpartner violent assault.

Psychological aggression, physical aggression, and injury in nonpartner relationships among men and women in treatment for substance-use disorders

OBJECTIVE

This study focused on the prevalence and predictors of psychological aggression, physical aggression, and injury rates in nonintimate partner relationships in a substance-use disorder treatment sample.

METHOD

The sample included 489 (76% men, 24% women) participants who completed screening measures for inclusion in a randomized control trial for an aggression-prevention treatment. Primary outcome measures included rates of past-year psychological aggression, physical aggression, and injury (both from the participant to nonpartners and from nonpartners to the participant). Potential predictors included individual factors (e.g., age, gender), developmental factors (e.g., family history of drug use, childhood physical abuse), and recent factors (e.g., depression, cocaine use).

RESULTS

Rates of participant-to nonpartner psychological aggression (83%), physical aggression (61%), and injury (47%) were high, as were rates of nonpartner-to-participant aggression. Bivariate analyses revealed significant relationships between the aggression outcomes and most of the individual, developmental, and recent factors. However, multivariate analyses (zero-inflated Poisson regression) revealed that age, treatment status, current symptoms of depression, heavy periods of drinking, and cocaine use were related most frequently to the occurrence of aggression to and from nonpartners.

CONCLUSIONS

Nonpartner aggression may be as common within a substance-use disorder sample as partner aggression, and it is associated with heavy drinking episodes, cocaine use, and depressive symptoms. The findings highlight the need for the development of effective violence interventions addressing violence in nonpartner relationship types.

Partner aggression among men and women in substance use disorder treatment: correlates of psychological and physical aggression and injury

This study examined intimate partner aggression in a sample of 489 participants enrolled in substance use disorder treatment, and expands on prior research by including measures of various forms of aggression, a mixed gender sample (76% men, 24% women), and measurement of several potential risk domains. Aggression measures included both participant-partner and partner-to-participant psychological aggression, physical aggression and injury. Analyses focused on the role of distal and proximal risk factors, including demographics, history of childhood physical and sexual abuse, and family history of problems with alcohol, drugs and depression, as well as recent substance use and symptoms of depression. Overall rates of participant-partner psychological aggression (77%), physical aggression (54%) and injuring partners (33%) were high, as were rates of partner-to-participant psychological aggression (73%), physical aggression (51%), and injury (33%). Several distal (family history variables, physical abuse) and proximal factors (binge drinking, several different drugs, depressive symptoms) were bivariately related to most of the aggression measures. However, according to multivariate analyses predicting aggression and injury measures, binge drinking and cocaine use were the drugs significantly associated with most measures, depression symptoms also were related to most aggression and injury measures, and a history of reported childhood physical abuse was related to all frequency of aggression and injury measures among those reporting such behaviors. Overall, the high rates of aggression among both men and women observed in this study further illustrate the need for interventions targeting substance use and aggression, and for further research regarding the inter-relationships among substance, aggression and depressive symptoms.