Follow-up study of anxiety disorder and alcohol dependence in comorbid alcoholism treatment patients

BACKGROUND: Anxiety disorders are present in a high percentage of alcoholism treatment patients. We tested the prediction that having a comorbid anxiety disorder increases the prospective risk for relapse to drinking after alcoholism treatment. We also explored the prospective associations of specific anxiety syndromes (and depression) with drinking and anxiety outcomes. METHODS: We assessed the diagnostic status and daily drinking patterns of 82 individuals approximately one week after they entered alcoholism treatment (baseline) and again approximately 120 days later (follow-up) (n=53). RESULTS: Consistent with study predictions, those with a baseline anxiety disorder (approximately 55%) were significantly more likely than others to meet various definitions of drinking relapse over the course of the follow-up. Regression models showed that baseline social phobia was the single best predictor of a return to any drinking after treatment, whereas panic disorder was the single best predictor of a relapse to alcohol dependence after treatment. Having multiple anxiety disorders (versus any specific anxiety disorder) at the baseline was the strongest predictor of having at least one active ("persistent") anxiety disorder at the follow-up. Cross-sectional analysis at the follow-up showed that anxiety disorder persisted in the absence of a relapse to alcohol dependence far more often than relapse to alcohol dependence occurred in the absence of a persistent anxiety disorder. CONCLUSIONS: Screening for comorbid anxiety disorder in alcoholism treatment patients is warranted and, where found, should be considered a marker of high relapse risk relative to that of noncomorbid patients. The capacity of specific anxiety treatment to mitigate relapse risk among comorbid patients remains an open question.     

Outcomes of Co-Morbid Alcoholic Men: A 1-Year Follow-Up

In this prospective, 1-year study, 360 males admitted to an inpatient alcoholism treatment program were administered a DSM-III compatible structured interview and subtyped by co-occurring psychiatric disorder. Forty percent satisfied diagnostic criteria for alcohol dependence while 27% met criteria for alcohol dependence and one additional psychiatric syndrome. The dually diagnosed patients were divided into: alcohol dependence plus drug abuse, alcohol dependence plus antisocial personality and alcohol dependence plus depression. These subtypes were compared on multiple dimensions at intake and at 1-year follow-up. At follow-up, all groups showed significant improvement in drinking and psychosocial functioning. The results suggest that subtyping alcoholics by co-morbid psychiatric disorders may be a good postdictor of clinical history, but a poor predictor of drinking outcome.     

Psychiatric disorders in older primary care patients

OBJECTIVE: Most older people with psychiatric disorders are never treated by mental health specialists, although they visit their primary care physicians regularly. There are no published studies describing the broad array of psychiatric disorders in such patients using validated diagnostic instruments. We therefore characterized Axis I psychiatric diagnoses among older patients seen in primary care. DESIGN: Survey of psychopathology using standardized diagnostic methods. SETTING: The private practices of three board-certified general internists, and a free-standing family medicine clinic. PARTICIPANTS: All patients aged 60 years or older who gave informed consent were eligible. MEASUREMENTS AND MAIN RESULTS: For the 224 subjects completing the study, psychiatric diagnoses were based on the Structured Clinical Interview for DSM-III-R. Point prevalence estimates used weighted averages based on the stratified sampling method. For the combined sites, 31.7% of the patients had at least one active psychiatric diagnosis. Prevalent current disorders included major depression (6.5%), minor depression (5.2%), dementia (5.0%), alcohol abuse or dependence (2. 3%), and psychotic disorders (2.0%). Dysthymic disorder and primary anxiety and somatoform disorders were less common and frequently comorbid with major depression. CONCLUSIONS: Mental disorders, particularly depression, are common among older persons seen in these primary care settings. Clinicians should be particularly vigilant about depression when evaluating older patients with anxiety or putative somatoform symptoms, given the relatively low prevalences of primary anxiety and somatoform disorders.     

Concurrent alcoholism and social anxiety disorder: a first step toward developing effective treatments

BACKGROUND: Social anxiety disorder (also called social phobia) is an anxiety disorder in which affected individuals fear the scrutiny of others. Clinical reports suggest that individuals with social anxiety disorder often use alcohol to alleviate anxiety symptoms, a practice that leads to alcohol abuse and/or dependence in approximately 20% of affected individuals. The present study investigated whether simultaneous treatment of social phobia and alcoholism, compared with treatment of alcoholism alone, improved alcohol use and social anxiety for clients with dual diagnoses of social anxiety disorder and alcohol dependence. METHODS: The design was a two-group, randomized clinical trial that used 12 weeks of individual cognitive behavioral therapy for alcoholism only (n = 44) or concurrent treatment for both alcohol and social anxiety problems (n = 49). Outcome data were collected at the end of 12 weeks of treatment and at 3 months after the end of treatment. RESULTS: Results with intent-to-treat analyses showed that both groups improved on alcohol-related outcomes and social anxiety after treatment. With baseline scores covaried, there was a significant effect of treatment group on several drinking measures. Counter to the hypothesis, the group treated for both alcohol and social anxiety problems had worse outcomes on three of the four alcohol use indices. No treatment group effects were observed on social anxiety indices. CONCLUSIONS: Implications for the staging of treatments for coexisting social phobia and alcoholism are discussed, as well as ways that modality of treatments might impact outcomes.     

Co-Morbidity of Lifetime Psychiatric Disorder Among Male Alcoholic Patients

The lifetime co-morbidity of major psychiatric disorders among male alcoholics was examined with the structured Psychiatric Diagnostic Interview (PDI), which was administered to 928 patients undergoing alcoholism treatment at six Veterans Administration Medical Centers. Thirty-eight percent were positive for alcoholism only; 62% fulfilled inclusive lifetime diagnostic criteria for at least one other additional psychiatric syndrome. Thirty percent satisfied criteria for one additional syndrome; 16% for two additional syndromes; 12% for three; and 4% for four or more disorders in addition to alcoholism. Depression and antisocial personality were the most frequently identified co-occurring syndromes (36% and 24%, respectively) followed by drug abuse and mania (17% each). The additional psychiatric syndromes in this sample were clearly not randomly distributed; instead, certain disorders tended to cluster together such as: drug abuse and antisocial personality; mania and depression; depression and anxiety disorder; and schizophrenia and affective disorder. Implications for classification and treatment are discussed.     

A Complex Relationship Between Co‐occurring Social Anxiety and Alcohol Use Disorders: What Effect Does Treating Social Anxiety Have on Drinking?

Background: Individuals with social anxiety disorder and co‐occurring alcohol problems report using alcohol to cope with anxiety symptoms. Interventions that reduce both social anxiety and drinking are needed. Paroxetine, an FDA‐approved medication to treat social anxiety disorder, reduces anxiety in individuals with co‐occurring alcohol problems. Objectives: To examine whether effective treatment of social anxiety with paroxetine reduces drinking in dual‐diagnosed individuals who endorse using alcohol to cope. Methods: A 16‐week, double‐blind, randomized controlled trial of paroxetine was conducted. Participants (placebo n = 22; paroxetine n = 20) met DSM‐IV diagnostic criteria for social anxiety disorder and alcohol abuse or dependence. Participants were seeking treatment for social anxiety, not for the alcohol problem. Alcohol use outcomes were measured with conventional quantity/frequency measures and novel measures of drinking to cope. Results: Paroxetine improved social anxiety more than placebo. Paroxetine reduced self‐reported reliance on alcohol for self‐medication purposes, but was not different than placebo in changing quantity and frequency drinking or the proportion of drinking days that were identified as coping‐related. Exploratory analyses revealed that for the placebo group, drinking during the trial was correlated with social anxiety severity, whereas for the paroxetine‐treated group, drinking was uncoupled from social anxiety severity. Conclusions: Successfully treating social anxiety symptoms with paroxetine does not reduce drinking in dual‐diagnosed individuals who are not seeking treatment for alcohol problems. Paroxetine does, however, reduce reliance on alcohol to engage in social situations, and may change the reasons why one drinks (such that drinking occurs for other reasons besides coping with anxiety). These results have implications for staging of social anxiety and alcohol treatment in individuals with the co‐occurring disorders presenting to a mental health or primary care provider.     

One-year incidence rate of major depression and other psychiatric disorders in 239 alcoholic men

The rate of depressive symptoms among alcoholics is high, but many of these syndromes appear to be alcohol-induced mood disorders and might not represent major depressive episodes independent of heavy drinking. The present study examines one aspect of the relationship between alcoholism and depression by evaluating the incidence of new episodes of major depressive disorders among alcohol-dependent men during the year following treatment. One year following discharge from an alcohol treatment program, structured face-to-face interviews were carried out with 239 primary alcoholic men, as well as additional informants. Approximately 4% of the men developed depressive episodes while drinking heavily, but only 2.1% demonstrated major depressions independent of heavy alcohol intake. There was no evidence of an increased incidence of any other major psychiatric disorder during the year of follow-up. These results are consistent with prospective studies of children of alcoholics and of longitudinal evaluations of general population samples. They do not indicate that in the present sample most primary alcohol-dependent men have elevated rates for major depressive disorders independent of alcohol-induced mood syndromes. However, it is likely that in the context of heavy drinking severe, although temporary, depressive episodes are likely to be observed.     

Correlation Between Medical and Behavioral Data in the Assessment of Alcoholism

Using the Munich Alcoholism Test, this study examined the prevalence and interrelationships of medical and sociobehavioral disorders in a nonhospitalized sample of 106 males who had been referred to a medical officer for "suspected" problems related to drinking. A further objective was to evaluate measurement properties of the Munich Alcoholism Test (MALT), a new diagnostic instrument for alcoholism. Self-report items focusing on the recognition of drinking problems formed a homogeneous and quite reliable scale. However, clinical signs and symptoms of disorders related to alcohol abuse occurred with relative independence of each other. In this predominantly young group of subjects, many individuals recognized that they had sociobehavioral problems, but few had clinical or laboratory manifestations of diseases associated with chronic alcohol abuse. These findings underscored the advantages of including both biomedical and sociobehavioral data for the early identification of alcohol abuse and dependence.     

Anxiety and the Development of Alcoholism

Theories concerning the etiology of alcoholism and commonly held beliefs suggest that anxiolytic effects of alcohol may be important in the development of problematic drinking. The effect of alcohol on anxiety has been studied through animal models, human experiments, and clinical observation. Human experiments have demonstrated that acute alcohol administration has anxiolytic effects. However, these effects depend on dose, the circumstances of administration, and subject characteristics. Systematic clinical observations show that anxiety disorders often precede and may contribute to alcohol abuse and dependence. Research is needed to determine the impact of anxiety symptoms on relapse and implications for treatment.     

Routine Depression Screening in an HIV Clinic Cohort Identifies Patients with Complex Psychiatric Co-morbidities Who Show Significant Response to Treatment

This study described characteristics, psychiatric diagnoses and response to treatment among patients in an outpatient HIV clinic who screened positive for depression. Depressed (25 %) were less likely to have private insurance, less likely to have suppressed HIV viral loads, had more anxiety symptoms, and were more likely to report current substance abuse than not depressed. Among depressed, 81.2 % met diagnostic criteria for a depressive disorder; 78 % for an anxiety disorder; 61 % for a substance use disorder; and 30 % for co-morbid anxiety, depression, and substance use disorders. Depressed received significantly more treatment for depression and less HIV primary care than not depressed patients. PHQ-9 total depression scores decreased by 0.63 from baseline to 6-month follow-up for every additional attended depression treatment visit. HIV clinics can routinely screen and treat depressive symptoms, but should consider accurate psychiatric diagnosis as well as co-occurring mental disorders.     

Comparison of Alcohol Dependence in Subjects from Clinical, Community, and Family Studies

This study contrasts the prevalence of alcohol-related symptoms, ages of onset of alcoholism milestones, and lifetime prevalence of other psychiatric disorders in three samples of alcohol-dependent individuals: alcoholics sampled from a variety of clinical settings (not necessarily alcoholism treatment facilities), relatives of alcoholic probands who participated in a Family Study of alcoholism, and alcoholics identified in the St. Louis Epidemiologic Catchment Area survey. Alcohol dependence (with or without abuse) was assessed using DSM-III diagnostic criteria for all samples. Clinical alcoholics had significantly more lifetime alcohol symptoms than Family Study and Community alcoholics and a significant excess of many alcohol symptoms. Onset information indicated that the three groups were similar in terms of appearance of milestones of alcohol dependence. For females aged 45 or younger, lifetime prevalence of major depression was high in both Clinical and Family Study alcoholics compared with Community alcoholics; male alcoholics from the Community Study had an excess of drug dependence. Findings suggest that, although alcoholics identified in clinical settings may have more severe alcohol dependence, certain types of psychiatric comorbidity are present to a greater degree in other samples of untreated alcoholics.     

Alcoholism and phobic anxiety—a clinical-demographic comparison

The prevalence of anxious and phobic symptoms in 97 alcohol-dependent and alcohol abuse patients, and that of alcohol abuse and dependence in 90 patients with panic/agoraphobia (PAG), were respectively determined in out-patients attending alcoholism and anxiety clinics in a university psychiatric hospital. The clinical and socio-demographic data of both the phobics and non-phobics of the alcoholic sample, and the alcohol dependents and non-dependents of the PAG sample, were compared. Panic attacks and phobias were associated with increased severity and worse prognosis for alcoholism. The infrequent instances of alcohol use to cope with anxiety in the PAG sample were associted with symptoms of social phobia. Alcohol abuse and dependence were more frequent in PAG men who used alcohol to cope with anxiety. Finally, the frequency and intensity of the panic and phobic symptoms of the alcoholic and PAG samples were contrasted. The alcoholism clinic patients with anxiety had less frequent and milder panic attacks. The predominant diagnosis of this group was agoraphobia, which was infrequent in the anxiety disorders clinic.     

Utilization of residential alcoholism treatment in bipolar disorder

Despite the high prevalence rate of comorbid alcohol dependence and bipolar disorder, little is known about how many bipolar patients are actively engaged in addiction treatment or the alcohol consumption characteristics of this group. This retrospective study reviewed the medical records from patients with alcohol dependence admitted to residential treatment at our institution (n = 588). The analyses focused on alcoholism severity measures and discharge clinical diagnoses. Patients with alcoholism + bipolar disorder compromised only 5% of the total study group. The number of drinking years was lower for patients with alcoholism + bipolar disorder (23.1 ± 17.7) than for those with alcoholism + depression (26.8 ± 13.9) or alcoholism alone (28.1 ± 13.2). A trend of higher mean lifetime maximum daily drinks was observed for patients with alcoholism + bipolar disorder; this was because of the significantly higher maximum drinks for women with bipolar disorder (21.0 ± 11.5) than for women in other diagnostic groups. Despite high rates of comorbidity in community-based studies, this retrospective study suggests that patients with bipolar disorder are not highly represented in residential alcoholism addiction treatment. Future studies are encouraged to better understand utilization rates of addiction treatment among patients with bipolar disorder and to identify clinical correlates that predispose bipolar women to high-dose drinking.     

Psychiatric comorbidity in treatment-seeking alcoholics: the role of childhood trauma and perceived parental dysfunction

BACKGROUND: This study among treatment-seeking alcoholics examined the relationship between childhood abuse (sexual abuse only [CSA], physical abuse only [CPA], or dual abuse [CDA]) and the presence of comorbid affective disorders, anxiety disorders, and suicide attempts, controlling for the potential confounding effects of other childhood adversities (early parental loss, witnessing domestic violence, parental alcoholism, and/or dysfunction) and adult assault histories. METHOD: We assessed 155 (33 females, 122 males) treatment-seeking alcoholics using the European Addiction Severity Index, the Structured Trauma Interview, and the Composite International Diagnostic Interview. RESULTS: The severity of childhood abuse was associated with posttraumatic stress disorder (PTSD) and suicide attempts in females and with PTSD, social phobia, agoraphobia, and dysthymia in males. Among men, multiple logistic regression models showed that CPA and CDA were not independently associated with any of the examined comorbid disorders or with suicide attempts. However, CSA independently predicted comorbid social phobia, agoraphobia, and PTSD. For the presence of comorbid affective disorders (mainly major depression) and suicide attempts, maternal dysfunctioning was particularly important. CSA also independently contributed to the number of comorbid diagnoses. For females, small sample size precluded the use of multivariate analyses. CONCLUSION: Childhood abuse is an important factor in understanding clinical impairment in treated alcoholics, especially regarding comorbid phobic anxiety disorders, PTSD, and suicidality. These findings underline the importance of routine assessment of childhood trauma and possible trauma-related disorders in individuals presenting to alcohol treatment services. More studies with bigger samples sizes of female alcohol-dependent patients are needed.     

Clinical correlates of desire for treatment for current alcohol dependence among patients with a primary psychiatric disorder

Background and Objectives: Rates of treatment-seeking for alcohol use disorders are notably low. To elucidate the clinical correlates of treatment-seeking for alcoholism, this study compared patients with current alcohol dependence and a primary psychiatric diagnosis who endorsed a desire for alcoholism treatment to patients who refused treatment or who were unsure.

Method: A total of 131 (54 females) psychiatric outpatients with current alcohol dependence completed an intake assessment at a large hospital-based psychiatric clinic and at the end of the intake were asked whether they would like to receive treatment for alcohol problems.

Results: Compared with alcohol-dependent patients who refused treatment for alcoholism or who were unsure (n = 46), patients who expressed a desire for treatment (n = 85) were older, were more likely to be female, reported higher levels of social impairments, and were more likely to endorse the following alcohol dependence symptoms: (i) multiple unsuccessful efforts or persistent desire to stop or cut down on their drinking; and (ii) drinking more than intended.

Conclusions: Approximately, 35% of patients who met current DSM-IV criteria for alcohol dependence reported no interest (or were unsure) in alcoholism treatment despite being engaged in treatment-seeking for another psychiatric disorder.

Scientific Significance: These findings extend previous epidemiological studies documenting treatment-seeking patterns for alcoholism by identifying clinical features associated with interest in treatment for this disorder among psychiatric outpatients.     

Psychiatric Disorders Among Drug Dependent Subjects: Are They Primary or Secondary?

The relationship between substance use disorders and comorbid psychiatric conditions was investigated among 425 persons in drug treatment who met DSM-III-R criteria for drug dependence. Using the NIMH Diagnostic Interview Schedule to ascertain DSM-III-R psychiatric disorders among these drug dependent subjects, lifetime prevalence rates were 64% for alcohol abuse/dependence, 44% for antisocial personality disorder, 39% for phobic disorders, 24% for major depression, 12% for dysthymia, and 10% for generalized anxiety disorder. We found that antisocial personality disorder and phobias generally had onsets prior to the onset of drug dependence (that is, they were primary disorders). The majority of drug dependent persons with generalized anxiety disorder reported an onset after the onset of drug dependence (that is, they had secondary generalized anxiety). Alcohol dependence, depression, and dysthymia were divided nearly evenly between earlier (primary disorder) and later (secondary disorder). These results are consistent with the body of literature indicating the importance of antisocial syndromes in the etiology of substance abuse and the literature indicating the complex, varying nature of the relationship of psychiatric disorders to substance dependence. Finally, a precise nomenclature for "age of onset," "primary," and "secondary" was developed for this study that is critical to understanding these issues and is recommended for other studies.     

Correlates of Alcohol Use Among Methadone Patients

This study examines the predictors of alcoholism among 201 patients from three methadone maintenance treatment programs (MMTPs) in New York City. Using the Michigan Alcohol Screening Test, one-fifth of the sample met criteria for alcohol dependence. Few subjects were currently enrolled in any form of chemical dependency treatment other than MMTP. Alcoholics started to use alcohol at an early age, and almost every alcoholic subject admitted to alcohol abuse before entering MMTPs. More alcoholics than nonalcoholics reported symptoms of somatization, obsessive-compulsive behavior, depression, phobic anxiety, and psychosis. Logistic regression indicated that alcoholism among MMTP patients was associated with years drinking, years of sharing needles, utilization of drug abuse detoxification but not alcohol detoxification, smaller increases in methadone dosage over time, and psychiatric symptomatology. Findings are discussed in terms of their implications for designing more efficacious treatment approaches for dually addicted patients in MMTPs.     

Alcoholism,antisocial behavior and family history*

Previous investigations in selected and clinical samples have demonstrated a close association between alcoholism and both antisocial behavior and a family history of problem drinking. This study uses the National Institute of Mental Health (NIMH) Epidemiological Catchment Area (EGA) data to assess this relationship in the general population in St. Louis, Missouri (U.S.A.). The results showed that serious antisocial behavior (both conduct disorder and antisocial personality disorder), gender, and a family history of problem drinking were all significantly associated with alcoholism (DSM-III alcohol abuse or dependence). Having either conduct disorder, antisocial personality, or a first-degree relative (parent, sibling, or child) with problem drinking increased the probability of alcoholism; being male also increased its probability. Antisocial behavior and gender interacted in that antisocial behavior was a more potent risk factor for women than for men. However, despite their close association with alcoholism, having either antisocial personality or a positive family history of problem drinking identified only 49% of male alcoholics and 14% of female alcoholics. Thus, these two important predictors of alcoholism would be somewhat inefficient screeners for primary prevention. More investigation is needed to understand the development of alcoholism in those without these major risk factors and the lack of alcoholism in those with them.     

Drinks of the father: father's maximum number of drinks consumed predicts externalizing disorders,substance use,and substance use disorders in preadolescent and adolescent offspring

BACKGROUND: The maximum number of drinks consumed in 24 hr seems to be an interesting phenotype related to alcoholism. The goal of the present study was to determine in an epidemiologic sample whether this measure of drinking history in fathers predicted externalizing behavioral disorders, substance use, and substance abuse in preadolescent and adolescent offspring and whether any such associations would be independent of paternal alcohol dependence diagnoses. METHODS: Subjects were male and female twins from both age cohorts of the Minnesota Twin Family Study, a population-based longitudinal study, and were approximately 11 or 17 years of age, respectively, upon study enrollment. In both age cohorts, diagnoses of conduct disorder, oppositional defiant disorder, and attention-deficit/hyperactivity disorder served as outcome measures. In addition, measures of lifetime substance use and of the presence of symptoms of substance abuse were derived for the 11-year-old cohort when subjects were approximately 14 years old and diagnoses of substance abuse were derived for the older cohort at age 17. An extension of logistic regression using generalized estimating equations served to assess whether paternal maximum alcohol consumption predicted filial outcome measures. RESULTS: Paternal maximum alcohol consumption was consistently associated with conduct disorder, substance use, and substance abuse or dependence in male and female offspring. These associations were not mediated by a primary effect of paternal alcoholism. CONCLUSIONS: Paternal maximum alcohol consumption was uniquely associated with those offspring characteristics most reliably found in adolescent children of alcoholic parents. This phenotype might supplement DSM diagnoses of alcohol dependence to reduce the number of false positives in genetic research.     

Adolescent Social Isolation as a Model of Heightened Vulnerability to Comorbid Alcoholism and Anxiety Disorders

Individuals diagnosed with anxiety‐related illnesses are at increased risk of developing alcoholism, exhibit a telescoped progression of this disease and fare worse in recovery, relative to alcoholics that do not suffer from a comorbid anxiety disorder. Similarly, preclinical evidence supports the notion that stress and anxiety represent major risk factors for the development of alcohol use disorder (AUD). Despite the importance of understanding the link between anxiety and alcoholism, much remains unknown about the neurobiological substrates underlying this relationship. One stumbling block has been the lack of animal models that reliably reproduce the spectrum of behaviors associated with increased vulnerability to these diseases. Here, we review the literature that has examined the behavioral and neurobiological outcomes of a simple rodent adolescent social isolation procedure and discuss its validity as a model of vulnerability to comorbid anxiety disorders and alcoholism. Recent studies have provided strong evidence that adolescent social isolation of male rats leads to the expression of a variety of behaviors linked with increased vulnerability to anxiety and/or AUD, including deficits in sensory gating and fear extinction, and increases in anxiety measures and ethanol drinking. Neurobiological studies are beginning to identify mesolimbic adaptations that may contribute to the behavioral phenotype engendered by this model. Some of these changes include increased excitability of ventral tegmental area dopamine neurons and pyramidal cells in the basolateral amygdala and significant alterations in baseline and stimulated catecholamine signaling. A growing body of evidence suggests that adolescent social isolation may represent a reliable rodent model of heightened vulnerability to anxiety disorders and alcoholism in male rats. These studies provide initial support for the face, construct, and predictive validity of this model and highlight its utility in identifying neurobiological adaptations associated with increased risk of developing these disorders.