The co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment

It is apparent from previous studies in clinical populations that there is a high comorbidity rate between alcoholism and other psychiatric diagnoses. However, this may simply be an expression of Berkson's bias (i.e., an increased tendency for persons with multiple diagnoses to seek and receive treatment and thus fall into study populations drawn from treatment sources). In this article, we use data from the Epidemiologic Catchment Area survey to examine the comorbidity between alcohol abuse and dependence, other substances of abuse and nonsubstance psychiatric disorders in a sample of approximately 20,000 persons drawn from the general population. We also examine the effect of comorbidity on psychiatric treatment. Every one of the psychiatric diagnoses we examined was more likely to occur in alcoholics than in nonalcoholics. Associations were particularly strong with antisocial personality disorder, other substance use and mania. The association between alcoholism and depressive disorders was positive but not very strong. The presence of other illnesses increased the likelihood of utilization of treatment services by alcoholics but did not increase the likelihood that drinking problems would be communicated to a doctor. The findings confirm prior studies of comorbidity in clinical samples and suggest the need for increased vigilance toward alcoholism by physicians.     

Patient factors predicting early alcohol-related readmissions for alcoholics: role of alcoholism severity and psychiatric co-morbidity

The current study was undertaken primarily to identify whether psychiatric co-morbidity was associated with the rate and time of alcohol-related inpatient readmissions for a group of 255 patients discharged from alcoholism treatment at a midwestern rural medical center. A structured interview obtained information regarding psychiatric disorders, including depression, antisocial personality disorders and polysubstance abuse, as well as alcohol history and sociodemographics. Ninety-eight subjects (38.4% of sample) were readmitted for alcoholism-related diagnoses within 15 months of discharge. Patients with a long history of heavy drinking, high daily alcohol consumption and history of previous alcoholism treatment were most likely to be readmitted with an alcoholism-related primary diagnosis. Once these variables were controlled for, other major psychiatric disorders, polysubstances abuse and sociodemographic variables did not appear to predict time to readmission. However, other potentially more sensitive outcome measures such as return to drinking were not evaluated in the present study.     

Stress response dampening: effects of gender and family history of alcoholism and anxiety disorders

One hundred and fifteen non-alcoholic social drinkers, ages 21–30 years, were selected on the basis of parental history of alcoholism and/or anxiety disorders to participate in a laboratory study of stress response dampening (SRD) effects of alcohol. The following four risk groups were identified based on the diagnoses of both parents: 1) alcoholism (ALC+), (2) alcoholism and anxiety disorder (ALCANX+), (3) anxiety (ANX+), and (4) no psychiatric diagnoses (FH–). Subjects were randomly assigned to receive a placebo or alcohol (0.85 g/kg) beverage, following which cardiovascular measures and self-reports of anxiety were monitored prior to, during and after a speech stressor. Women with a family history of alcoholism and women with a family history of anxiety disorders showed strong SRD effects of alcohol on heart rate and pulse transit time. Men with a family history of anxiety disorders showed evidence of increased subjective response to stress during the alcohol beverage condition. Finally, SRD effects of alcohol were not found for male subjects, and this was attributed to their heavier drinking histories and lower breath alcohol levels as compared to women. Implications of the SRD effects in women are discussed in the context of the comorbid association between alcoholism and anxiety disorders. Received: 16 October 1996/Final version: 14 November 1997     

Suicide attempts and alcoholism

This study examined the association among suicide attempts, parental alcoholism, psychopathology and drinking history in a sample of hospitalized alcoholics. Suicide attempters were found to have multiple psychiatric diagnoses (e.g., depression, antisocial personality disorder and substance abuse) and more severe psychiatric symptoms than nonattempters. Alcoholic suicide attempters also tended to have a parental history of alcoholism and began abusing alcohol at an early age. Alcohol abuse symptoms during the month before, and 6 months before, the current hospitalization were generally similar for suicide attempters and nonattempters. Clinical implications of the findings are discussed.     

P3 components and adolescent binge drinking in Southwest California Indians

In adolescence, consuming a large number of drinks over a short interval of time (e.g. binging) is not an uncommon occurrence. Since adolescence is an important neurodevelopmental period, the effect of binge drinking on brain and behavior has become a significant health concern. The present study evaluated event-related potentials (ERPs) in young adult Southwest California Indians who had a history of binge drinking during their adolescence. One hundred twenty five participants who were currently 18-25 yrs of age who were free of Axis I psychiatric diagnoses were categorized as: 1) reporting no binge drinking during adolescence (>5 drinks per occasion before age 18) or drug dependence diagnoses 2) reporting binge drinking during adolescence with no drug dependence diagnoses 3) reporting binge drinking during adolescence and drug dependence diagnoses. ERPs were collected using a facial discrimination task. Adolescent alcohol and drug exposure was found to be associated with decreases in the latency of an early P3 component (P350). Decreases in a later component amplitude (P450) were also found in young adults exposed to alcohol, and those exposed to alcohol and drugs. However, that finding appears to be a combined result of predisposing factors such as family history of alcoholism and presence of other externalizing diagnoses. Taken together these preliminary studies suggests that adolescent binge drinking may result in a decreases in P3 component latencies and amplitudes perhaps reflecting a loss or delay in the development of inhibitory brain systems.     

Alcohol Habits and Health Care Use in Patients with Psychiatric Disorders

Objective: It is common for persons with psychiatric disorders to also have alcohol problems. Studies in the general population as well as in clinical samples have found hazardous or harmful alcohol habits to be particularly prevalent in the presence of psychiatric disorders. This study sought to explore the relationships between drinking habits and health care utilization (psychiatric as well as general medical) in persons seeking psychiatric treatment and to investigate the associations among age, sex, and type or number of diagnoses and health care use and costs. For the planning of targeted interventions, we also sought to identify subgroups with a high prevalence of hazardous drinking habits. Methods: From a psychiatric clinic for affective disorders at a university hospital in Sweden, patients who had been screened for hazardous drinking (N = 609) were selected. Patients with primary psychosis or substance use disorder receive treatment at other clinics and did not participate. Medical records data were grouped and compared. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) was used for diagnoses and the Alcohol Use Disorders Identification Test for screening. Patients were grouped by drinking habits and sex, age, and diagnosis group, and their psychiatric as well as general medical health care use was compared. Results: Abstainers used psychiatric care more than all other drinking groups (p < .001). Psychiatric health care costs were higher in abstainers and low-risk drinkers (1.64 to 1). No differences in general medical care could be identified between drinking groups. Specific subgroups with higher rates of hazardous drinking could not be identified (44% of all males and 34% of all females reported such habits). Inconclusive results from previous research are most likely due to different methods used to classify drinking problems. Conclusions: Abstainers and low-risk drinkers used psychiatric health care to a higher cost than the other drinking groups. Possible explanations are discussed from a clinical and scientific perspective. This study clarifies the need for uniform measures when classifying alcohol use in studies of relationships between alcohol use and health care use. There is also a need to separate former drinkers from abstainers in future studies.     

Isolating the effect of alcoholism treatment on medical care use

OBJECTIVE: This study seeks to refine the analysis of the effects of alcoholism treatment on subsequent use of medical care by examining components of the latter. METHOD: Claims and encounter data of 29,122 adults (mean age 40, 35% female) receiving benefits from both a mental health managed care program and its parent medical care insurance company who had a diagnosis of alcoholism were analyzed using a longitudinal Poisson regression model fit by the generalized estimating equation method to compare differences between the groups in medical utilization before and after alcoholism treatment. The diagnoses associated with medical care were assigned to one of four groups: alcohol specific, alcohol acute, alcohol chronic and nonalcohol related. All persons applying for alcoholism treatment benefits were included; those who had fewer than four visits for alcoholism treatment served as controls. RESULTS: The largest effect of alcoholism treatment is seen for medical encounters associated with diagnoses that reflect the acute effects of intoxication. The frequency of encounters related to conditions associated with chronic alcohol misuse were the only type that did not significantly decline 1 year past treatment in the outpatient treatment group. CONCLUSIONS: This study provides support for the belief that treatment for alcoholism is directly associated with a change in medical care use. However, the findings suggest that the impact on utilization varies with the type of medical care. The most pronounced effects appear to be for acute problems that may be most directly attributed to the effects of active drinking. Changes in medical utilization in this area, therefore, may be responsible for the cost-offset of alcoholism treatment that has been observed in prior research.     

Comparing the ICAS and the MAC as Indirect Alcoholism Scales: Methodological Considerations and Implications for Further Research

Four groups of domiciliary residents were studied with the Institutionalized Chronic Alcoholic Scale (ICAS) and MacAndrew Scale (MAC) to determine the more effective indirect alcoholism scale. The groups included: (a) 48 alcoholics, (b) 27 residents with alcoholism and other psychiatric diagnoses, (c) 24 residents with psychiatric diagnoses only, and (d) 22 with only medical diagnoses. MacAndrew had omitted two alcohol usage items from the 51 item MAC in order to develop a more effective indirect scale, free of alcohol usage items. A similar omission technique was employed with the ICAS in the current study. ANOVA indicated that the MAC was the more effective indirect scale.     

Alcohol expectancies,alcohol consumption,and problem drinking: the moderating role of family history

The purpose of this investigation was to examine the moderating role of family history (FH) of alcohol use disorders on the association between positive alcohol expectancies and drinking behavior (quantity/frequency of drinking and alcohol-related problems). Lifetime DSM-III-R diagnoses of alcohol abuse/dependence in probands from the Yale Family Study were used to classify FH status of adult relatives, yielding 149 relatives of probands with alcohol abuse/dependence and 110 relatives of controls. Significant main effects were found for FH of alcoholism on problem drinking symptoms and for alcohol expectancies concerning both problem drinking symptoms and quantity/frequency of alcohol use. Regarding moderating effects, there was a significant interaction between alcohol expectancies and FH only for problem drinking symptoms. When familial density of alcoholism was examined as a moderator, significant effects were found for all drinking variables, thus demonstrating that the degree to which alcohol expectancies was associated with the drinking outcomes varied by the extent to which alcohol use disorders clustered in families. The findings are discussed in terms of the interaction of alcohol-related risk factors and the importance of using multiple indicators of familial vulnerability.     

A comparison of familial and nonfamilial male alcoholic patients without a coexisting psychiatric disorder

Both family history of alcoholism and the presence of additional psychiatric disorder in male alcoholic patients are associated with an earlier onset of problem drinking, greater alcoholism severity and poorer clinical outcomes. To assess the relative contribution of family history alone, a sample of 212 male alcoholics not positive for any other psychiatric disorder was selected and divided into those with a family history of alcoholism (FH+) or no family history of alcoholism (FH-) among first degree relatives. Although FH+ alcoholics reported a younger age of onset of problem drinking and greater severity of some alcohol-related sequelae, the differences were not as extensive or pronounced as those found in a previous study of a sample of psychiatrically heterogeneous patients (Penick et al., 1987). A bi-dimensional typology of alcoholism incorporating both additional psychiatric diagnoses and a positive family history of alcoholism is suggested.     

Drinking patterns and alcohol problems among Hispanics in the U.S.: a review

The literature on drinking patterns and alcohol problems among Hispanic Americans is critically reviewed. The picture provided by studies which have been examined indirect indicators of alcohol problems is contradictory. Some results suggest that Hispanics in the U.S.A. are over-represented among alcohol-related deaths and among those arrested for drunk driving and in treatment in alcoholism programs. Other studies do not provide evidence of over-representation. Studies in the general population indicate that there is more heavy drinking and alcohol-related problems among Hispanics than among other ethnic groups in the U.S.A. general population. However, very few of these studies were specifically designed to evaluate alcohol use and problems among this ethnic group, and these results are based on the analysis of a small number of Hispanic respondents. In the conclusions this and other methodological limitations are discussed and new areas for study are proposed.     

The coping styles of alcoholics with axis II disorders

This study investigated the drinking triggers and coping styles of alcoholics with coexisting personality disorders (PDs). Forty-eight outpatients in alcohol treatment (75% men) were assessed with a structured interview for PD diagnoses and were divided into two groups: those with one or more PD diagnoses (n = 29) and those with no personality disorder (NPD) diagnoses (n = 19). Relative to NPD participants, PD participants had greater alcoholism severity and were more likely to have another Axis I psychiatric diagnosis. All subsequent analyses used these variables as covariates. Utilizing analyses of covariance (ANCOVAs), the groups were compared on triggers for heavy drinking and coping styles. The PD group was more likely to report negative emotions, interpersonal conflict, and testing personal control as triggers for heavy drinking, as well as having an emotion-oriented coping style. There were no differences in task or avoidant coping styles.     

Effect of major depression and antisocial personality on alcoholism: course and motivational patterns

Major depression and antisocial personality are two diagnoses often associated with alcoholism. The relationship of these two diagnoses to the course of alcoholism and on the motivation for alcohol use was examined in a sample of 321 persons receiving inpatient treatment for alcoholism. Major depression did not alter the course of alcoholism in either men or women. However, patients with a history of major depression more frequently reported drinking to relieve symptoms related to depression than patients without a history of major depression. Patients with antisocial personality had an earlier onset of alcohol-related problems than patients without antisocial personality. The motivational patterns for drinking did not distinguish patients with antisocial personality from patients without antisocial personality. These findings indicate the etiological logical importance of antisocial personality for the development of alcoholism and highlight the patients' perception of depression as an explanation for their drinking.     

Children of alcoholic parents in the community

The relationship between parental alcoholism and risk for maladjustment in the offspring was investigated in a community sample. Children of parents who met criteria for DIS/DSM-III alcohol abuse or dependence and children of parents who met criteria for ten other diagnoses were compared to children of "normal" parents. The data were obtained from the merging of the data banks of two major psychiatric epidemiology studies of the adult (17-64) and child (4-16) population of Puerto Rico. Results indicated that parental alcoholism in addition to creating an adverse family environment had an effect on the relative risk for maladjustment in the offspring (as measured by scores on the Child Behavior Checklist). Although previous studies have reported higher levels of externalizing behaviors in children of alcoholics, an increased risk for internalizing symptoms was observed in the children studied. Similar findings were obtained for the children of parents with other psychiatric disorders suggesting that the effects of parental alcoholism in children ages 4 to 16 may not be different from the consequences of parental mental illness per se.     

Assessing parental alcoholism: a comparison of the family history research diagnostic criteria versus a single-question method.

This study compares two methods of determining parental alcoholism: (1) a single question asking whether one of the subject's parents had alcohol problems; (2) the Family History Research Diagnostic Criteria (FH-RDC), which require at least one alcohol-related problem in addition to parental problem drinking. We sought first to determine the level of agreement between the single-question approach and the full FH-RDC for parental alcoholism, and then to gauge how much bias will be introduced by using the single question rather than the FH-RDC-method in assessing the risk for psychiatric disorders. Data were taken from the National Comorbidity Survey (NCS), a nationwide survey of the noninstitutionalized US civilian population aged 15 to 54. Parental alcoholism was assessed both by the single question and by the full FH-RDC. Psychiatric disorders were assessed with the Composite International Diagnostic Interview (CIDI). Good agreement was found between the single-question approach and the FH-RDC (kappa = 0.83). The single-question method introduces only a small downward bias when it comes to assessing the risk for psychiatric disorders in children of alcoholic probands. This underestimation does not reach statistical significance. When a questionnaire needs to be shortened, a single question on parental problem drinking is a good alternative to checking all individual FH-RDC items.     

DSM-IV alcohol dependence and abuse: further evidence of validity in the general population

BACKGROUND: In order to understand the validity of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) alcohol abuse and dependence diagnoses, studies are needed in both clinical and general population samples. The purpose of this study was to examine the construct and criterion-oriented validity of DSM-IV alcohol dependence and abuse in the general population with respect to factor structure and their relationship to family history of alcoholism, treatment utilization, and psychiatric comorbidity. METHODS: This analysis is based on data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), in which nationally representative data were collected in personal interviews conducted with one randomly selected adult in each sample household or group quarters. A subset (n=26,946) of the NESARC sample (total n=43,093) who reported drinking one or more drinks during the year preceding the interview formed the basis of analyses. Latent variable modeling was used to assess the concurrent validity of DSM-IV alcohol abuse and dependence symptom items. RESULTS: The latent variable modeling yielded one major factor related to alcohol dependence, a second factor related to alcohol abuse and a third smaller factor defined by tolerance. The validity of alcohol dependence in general population samples was further supported by statistically significant associations with family history of alcoholism, treatment utilization, and psychiatric and medical comorbidities. CONCLUSIONS: The factor structure and relationship to external criterion variables observed in the study provide support for the further validity of DSM-IV alcohol dependence in the general population, whereas support for the validity of DSM-IV abuse was equivocal.     

Older adult controlled drinkers and abstainers

Little is known about the lifetime course of alcohol problems, especially during late adulthood. Many individuals with a history of alcohol problems achieve remission of their symptoms through abstinence or controlled drinking. This study examined 135 older adults with a prior history of alcohol diagnoses who were symptom free for at least the past year. Two groups were identified based on their alcohol consumption within the past year: abstinent individuals (n = 92) and controlled drinkers (n = 43). The groups did not differ in age, racial composition, education, income, or years since their last alcohol-related symptom, but they did differ in gender composition, indices of alcoholism severity, history of formal and informal treatment, as well as lifetime alcohol consumption patterns. Abstinent individuals had more severe alcohol problems, consumed higher amounts of alcohol on drinking days, had more years of heavy alcohol consumption, and were more likely to have attended alcohol treatment and Alcoholics Anonymous (AA). The controlled drinkers had a longer history of moderate social drinking, and their current consumption habits appeared to be similar to symptom-free older adult drinkers. The results suggest that gender, alcoholism severity, history of formal and informal treatment, and past consumption patterns are associated with whether older adults with histories of alcoholism attain successful outcomes through abstinence or controlled drinking.     

Pharmacogenomics of alcohol response and addiction

Alcoholism is a complex psychiatric disorder that has high heritability (50-60%) and is relatively common; in the US the lifetime prevalence of alcohol dependence is 20% in men and 8% in women. Current psychosocial and pharmacological therapies have relatively modest effects. Treatment is complicated by the fact that alcoholism is often co-morbid with other disorders, including anxiety, depression, and antisocial personality disorder. Approximately 80% of alcoholics smoke cigarettes and there is considerable genetic overlap between nicotine and alcohol addiction. Convergent evidence supports the classification of alcoholics into two broad categories: type 1 - later onset with feelings of anxiety, guilt, and high harm avoidance; and type 2 - early age of onset, usually men, impulsive, antisocial, and with low levels of brain serotonin. The pharmacogenomics of alcohol response is well established; genetic variants for the principal enzymes of alcohol metabolism influence drinking behavior and protect against alcoholism. Vulnerability to alcoholism is likely to be due to multiple interacting genetic loci of small to modest effects. First-line therapeutic targets for alcoholism are neurotransmitter pathway genes implicated in alcohol use. Of particular interest are the 'reward pathway' (serotonin, dopamine, GABA, glutamate, and beta endorphin) and the behavioral stress response system (corticotrophin-releasing factor and neuropeptide Y). Common functional polymorphisms in these genes are likely to be predictive (although each with small effect) of individualized pharmacological responses. Genetic studies, including case-control association studies and genome wide linkage studies, have identified associations between alcoholism and common functional polymorphisms in several candidate genes. Meanwhile, the current pharmacological therapies for alcoholism are effective in some alcoholics but not all. Some progress has been made in elucidating the pharmacogenomic responses to these drugs, particularly in the context of the type 1/type 2 classification system for alcoholics.     

What Aspects of Human Alcohol Use Disorders Can Be Modeled Using Selectively Bred Rat Lines?

The use of selective breeding to produce animal models for the study of alcohol abuse and alcoholism represents one of the major advances in the field of alcohol research. Rats selectively bred for alcohol preference and alcohol nonpreference have been useful to both preclinical and clinical investigators in the alcohol research community for studying the behavioral, neurobiological, and molecular basis of alcohol drinking, for identifying the genes that may contribute to the development of alcohol abuse and alcoholism, and for evaluating the utility of drugs aimed at reducing alcohol intake and preventing alcohol relapse. Rats selectively bred for alcohol preference (alcohol preferring or “P” line) have enhanced responsiveness to the low dose reinforcing effects of alcohol, less aversion to moderate/high doses of alcohol, and are able to develop tolerance to the aversive effects of alcohol more rapidly and to maintain tolerance longer than rats selectively bred for alcohol nonpreference (alcohol nonpreferring or “NP” line). The increased potency of low-dose alcohol as a reinforcer for P rats might be expected to foster and maintain alcohol drinking. Weaker aversion to the pharmacological effects of moderate/high doses of alcohol in the P line would allow P rats to drink more alcohol than NP rats before the postingestional effects become aversive. Rapid induction of tolerance to the aversive effects of alcohol with repeated bouts of voluntary alcohol drinking, as well as persistence of alcohol tolerance in rats of the P line might serve to maintain alcohol drinking. These are powerful mechanisms that may serve to promote and maintain a high alcohol drinking behavior. Although these rat lines have been used to address several characteristics of excessive alcohol consumption in humans, they have not yet been used to model several aspects of human alcohol use disorders. New applications of these selectively bred rat lines are discussed which may further our understanding of the factors contributing to alcohol abuse and alcoholism.     

Maximizing Scarce Service Resources in a Rural Mental Health Clinic: Should Alcoholics Be Treated in Separate Programs?

One hundred nineteen patients at rural community mental health centers were divided into three diagnostic groups and compared to determine if alcoholic and nonalcoholic patients differ significantly in terms of psychopathology. The three diagnostic groups were (1) primary diagnosis of alcoholism (N = 34), (2) primary diagnosis of emotional disturbance (N = 39), and (3) “other” diagnoses (N = 46). These groups were compared with respect to demographic variables, alcohol drinking patterns, psychopathology, and attitude toward treatment. The alcoholic patient group tended to be single, male, and inpatients; while the nonalcoholic group tended to be married, female, and outpatients. These groups differed significantly with respect to alcohol consumption and drinking patterns and effects, but did not differ significantly with respect to their attitudes toward mental illness or their MMPI profiles. The results of the “other” diagnostic group generally fell between those of the alcoholic and nonalcoholic groups, suggesting that it was a heterogeneous group of subjects. The total subject population evidenced elevated MMPI profiles, indicating the presence of a high level of psychopathology, but there was no clear distinction between the alcoholics and the other groups in terms of type or degree of psychopathology. Implications for treatment are discussed.