While perceived stigma and social support were only assessed at the follow-up interview, higher PAS was associated, by way of mediation through lower levels of perceived social support, with the persistence of AUD and an increased risk internalizing psychiatric disorder over the follow-up period of NESARC. Based on mediation ratios, a substantial portion of the relationships between PAS and psychiatric outcomes were mediated by perceived social support. The finding of mediation is in line with a prior study on depression stigma, which demonstrated that reduced social support mediated the relationship between perceived stigma and quality of life (Chung et al., 2009). Lower levels of social support may be an important mechanism via which the perceived stigma of AUDs is associated with psychiatric outcomes. With cross-sectional data, we were unable to determine if these associations may be causal in nature. We cannot rule out reverse causality, and it is also possible that bi-directional relationships exist between these variables. For example, AUD persistence and/or internalizing disorder may reduce social support, lead people to perceive more stigma, and/or heighten sensitivity to the potential
