Perception of sleep in recovering alcohol-dependent patients with insomnia: relationship with future drinking

BACKGROUND: Subjective and objective measures of poor sleep in alcoholic insomniacs predict relapse to drinking. Nonalcoholic insomniacs underestimate their total sleep time (TST) and overestimate their sleep onset latency (SOL) and wake time after sleep onset (WASO) compared with polysomnography (PSG). This study evaluated 3 hypotheses: (1) subjective SOL would predict frequency of future drinking; (2) participants would overestimate SOL and WASO and underestimate TST; and (3) higher amounts of over- and underestimates of sleep at baseline would predict worse drinking outcomes prospectively. METHODS: Participants (N=18), mean age 44.6 years (+/-13.2), underwent an adaptation night and then 2 nights of PSG 3 weeks apart. They also provided morning estimates of SOL, WASO, TST, and sleep efficiency (SE). Following the baseline PSG, participants were followed over 12 weeks. A 2-way ANOVA (night x method of measuring sleep) compared results and regression analyses predicted drinking. Drinking outcomes were defined as number of days drinking (DD) and number of heavy-drinking days (HDD) during 2 consecutive 6-week follow-up periods. RESULTS: Most participants (72%) overestimated SOL by a mean of 21.3 (+/-36) minutes compared with PSG [F(1, 14)=7.1, p<0.03]. Unexpectedly, 89% underestimated WASO by a mean difference of 48.7 (+/-49) minutes [F(1, 14)=15.6, p<0.01]. Drinking during the first 6-week study period was predicted by both subjective estimates of WASO and their accuracy, whereas drinking during the second 6-week period was predicted by both subjective estimations of sleep and rapid eye movement sleep latency. CONCLUSION: Greater subjective accuracy of wakefulness at night provided by the patient predicted drinking during the study. Unlike nonalcoholic insomniacs, this alcoholic sample significantly underestimated WASO compared with PSG values. The predictive ability of sleep parameters depended on the selected measure of drinking outcomes and when outcomes were measured. Subjective sleep measures were better predictors of future drinking than corresponding PSG measures.     

A comparison of correlates of DSM-IV alcohol abuse or dependence among more than 400 sons of alcoholics and controls

BACKGROUND: Alcohol dependence and abuse are defined as separate disorders. However, relatively few data are available about whether the same characteristics predict both syndromes. METHODS: Complete data were available from the 15 year follow-up of 411 men who originally had been evaluated from a university population at about age 20. Both baseline data gathered prospectively and the retrospective ratings in six domains of life functioning were analyzed for their relationship to the development of alcohol abuse or dependence during the follow-up. RESULTS: Baseline characteristics of a family history of substance use disorders, the quantity and frequency of drinking, the history of alcohol-related problems, and the level of response to alcohol all predicted future alcohol abuse or dependence, but only an alcoholic second-degree relative or a first-degree drug-dependent family member differentially predicted dependence. Logistic regression analyses revealed that similar baseline characteristics combined to predict dependence and, separately, abuse. When the domains of functioning during the 15 years were included, positive alcohol expectancies, poor coping mechanisms, low level of social support, and drinking in the environment contributed to both dependence and abuse, although the relationship was stronger for dependence. CONCLUSIONS: The predictors and correlates of alcohol abuse and dependence in this group of men were similar. Further research in additional populations and on other drugs is needed to determine if the two syndromes overlap sufficiently to be combined.     

Alcohol dependence and abuse diagnoses: concurrent validity in a nationally representative sample

The Alcohol Dependence Syndrome concept has had a widespread influence on the major nosological classification systems, most recently with its operationalization as DSM-IV alcohol dependence. Although many studies have provided evidence of the validity of the Alcohol Dependence Syndrome in clinical samples, little validation work has been conducted in general population samples on DSM-IV alcohol dependence or the distinction of DSM-IV alcohol dependence from DSM-IV alcohol abuse. We therefore examined the cross-sectional validity of DSM-IV alcohol dependence and abuse in 27,616 household residents who participated in a 1992 national survey on alcohol use disorders. Validity was investigated by testing the association of a set of five "criterion" variables, external to the alcohol diagnostic criteria, with dependence and abuse diagnoses. Results indicated that dependence diagnoses were significantly associated with all criterion variables when compared with those with no diagnosis and also when compared with alcohol abuse. This supported the separation of dependence from abuse. Abuse diagnoses were associated with some, but not all, criterion variables when compared with subjects with no diagnosis. This report replicates many aspects of a similar investigation in a community sample of household residents. Implications for the next steps in research are discussed.     

Insulin but not insulin growth factor-1 correlates with craving in currently drinking alcohol-dependent patients

Background:  Preclinical data suggest that brain insulin and insulin growth factor-1 (IGF-1) may contribute to the development of addiction. The aim of this clinical study was to evaluate the relationships between insulin and IGF-1 plasma concentrations and alcohol craving.
Methods:  The correlations between insulin and craving in actively drinking alcoholics were evaluated in the experiment 1 retrospectively and in the experiment 2 in a case-control study. Experiment 3 evaluated the correlations between insulin and craving in 12-weeks abstinent alcoholics in a longitudinal study. C-peptide and IGF-1 were also investigated in experiments 2–3. Alcohol craving was evaluated by the Obsessive–Compulsive Drinking Scale (OCDS).
Results:  Significant positive correlations between insulin concentrations and craving scores were found in actively drinkers ( p  < 0.05). Specifically, in the first experiment insulin significantly correlated with the compulsive scores. In the second experiment and in an analysis of experiments 1–2 together, insulin plasma concentration correlated with total OCDS craving ( p  < 0.05) and compulsive craving ( p  < 0.05) and showed a trend of correlation with the obsessive craving. At 12 weeks no correlation was found between insulin and craving scores. In all the experiments the correlations between C-peptide and craving were close to the ones between insulin and craving while IGF-1 never correlated with craving.
Conclusions:  This study suggests that insulin could be involved in the neurobiology of alcohol craving and addiction. This characteristic seems specific of insulin since similar data were found on C-peptide but not on IGF-1. Future confirming studies on larger samples are needed, also to investigate possible therapeutic implications.     

A randomized double-blind pilot trial of gabapentin versus placebo to treat alcohol dependence and comorbid insomnia

Background:  Insomnia and other sleep disturbances are common, persistent, and associated with relapse in alcohol-dependent patients. The purpose of this pilot study was to compare gabapentin versus placebo for the treatment of insomnia and prevention of relapse in alcohol-dependent patients.
Methods:  Twenty-one subjects, including 10 women who met study criteria for alcohol dependence and insomnia and expressed a desire to abstain from alcohol, were recruited to the study. During a 1 to 2 week placebo lead-in and screening phase, a complete medical history, physical exam, blood tests, urine drug test, and structured interviews were performed to determine eligibility and patterns of alcohol use and sleep. Insomnia due to intoxication or acute withdrawal, psychiatric or medical illness, medications, and other sleep disorders were ruled out. Subjects were then randomized to either placebo ( n  = 11) or gabapentin ( n  = 10) for 6 weeks and titrated over a 10-day period to 1,500 mg or 5 pills at bedtime. After a 4-day taper, subjects were reassessed 6 weeks after ending treatment.
Results:  Gabapentin significantly delayed the onset to heavy drinking, an effect which persisted for 6 weeks after treatment ended. Insomnia improved in both treatment groups during the medication phase, but gabapentin had no differential effects on sleep as measured by either subjective report or polysomnography.
Conclusion:  Because gabapentin is a short-acting medication that was taken only at nighttime in this study, it may possibly exert a nocturnal effect that prevents relapse to heavy drinking by a physiological mechanism not measured in this pilot study.     

Demographic characteristics, life context, and patterns of substance use among alcohol-dependent treatment clients in a health maintenance organization

BACKGROUND: Although individuals dependent only on alcohol and those dependent on both alcohol and drugs typically are not studied together in clinical trials, they are treated together in most treatment programs. In this study we compared epidemiological characteristics of the alcohol-only and alcohol-and-drug dependents in a treatment sample to assess differential treatment needs. METHOD: Patients admitted to treatment at a health maintenance organization's chemical dependency program were sampled and interviewed by using a structured questionnaire. The sample included 491 alcohol-only and 217 alcohol-and-drug dependents. Demographic characteristics, lifetime and current substance use, Addiction Severity Index composite scores, and DSM-IV criteria for alcohol and drug dependence were assessed at admission. RESULTS: The odds of alcohol-and-drug dependence were higher among males, African Americans (when compared with whites), those who were younger, and those with less than college education. The risk was also higher among those who initiated heavy drinking or drug use before the age of 18. Increased psychiatric and family/social problems also were associated with combined dependence. CONCLUSIONS: Even in this relatively homogeneous socioeconomic status population, demographic characteristics were important predictors of type of dependence. Treatment programs which provide services that address prevention and psychosocial problems should pay attention to age of initiation as well as psychiatric and social problems.     

Screening for alcohol problems in the U.S. general population: comparison of the CAGE,RAPS4, and RAPS4-QF by gender,ethnicity, and service utilization. Rapid Alcohol Problems Screen

BACKGROUND: The purpose of this study was to compare the performance (sensitivity and specificity) of two brief screening instruments, CAGE and the Rapid Alcohol Problems Screen 4 (RAPS4), against ICD-10 and DSM-IV criteria for alcohol dependence and abuse in a representative sample of the U.S. adult household population by gender, ethnicity, and service utilization (emergency room and primary care) in the last year. METHODS: Data are from the Alcohol Research Group's 2000 National Alcohol Survey (n = 7612), which is a computer-assisted telephone interview survey of the U.S. general population 18 and over in all 50 U.S. states and the District of Columbia. RESULTS: Sensitivity of the RAPS4 (0.86) was better than the CAGE (0.67) given similar specificity (0.95 vs. 0.98) and outperformed the CAGE for alcohol dependence across all gender, ethnic, and service utilization groups, except among blacks and Hispanics. The RAPS4 also performed equally well for females and males (0.88 vs. 0.85), whereas sensitivity of the CAGE was lower for females. Although sensitivity of the RAPS4 was better than the CAGE for alcohol abuse, sensitivity was low for both (0.56 and 0.36, respectively). When quantity-frequency (QF) questions (drinking five or more drinks on at least one occasion during the last year and drinking as often as once a month during the last year) were added to the RAPS4, the RAPS4-QF performed significantly better for alcohol abuse and outperformed the CAGE at a cut point of one across all gender, ethnic, and service utilization groups. The RAPS4-QF appeared to be most sensitive for alcohol abuse among both males and females reporting emergency room use (0.90). CONCLUSIONS: The data suggest that the RAPS4 outperforms the CAGE in this general population sample. The addition of a QF question to the RAPS4 improves performance in relation to sensitivity for alcohol abuse, and the RAPS4 and RAPS4-QF may be the instruments of choice in brief screening for alcohol use disorders. Additional research is needed to further explore these issues.     

Age at first drink and risk for alcoholism: a noncausal association

Prior research indicates risk for alcoholism is increased among individuals who begin to drink at an early age. We replicate and extend these findings, addressing causal and noncausal explanations for this association. Structured psychiatric interviews, including assessment of lifetime DSM-IV alcohol abuse and alcohol dependence (AD), were conducted with 8746 adult twins ascertained through a population-based twin registry. We found strong evidence for an association between early drinking onset and risk for AD, but less evidence for an association with alcohol abuse. The results of twin-pair analyses suggest that all of the association between early drinking and later AD is due to familial sources, which probably reflect both shared environmental and genetic factors. These results suggest the association between drinking onset and diagnosis is noncausal, and attempts to prevent the development of AD by delaying drinking onset are unlikely to be successful.     

Decision-making deficits in alcohol-dependent patients with and without comorbid personality disorder

BACKGROUND: Impairments in decision making are a consistent finding in substance use disorder (SUD) populations. However, decision-making deficits are not specific for SUDs and are also reported in the context of other psychiatric disorders such as antisocial and borderline personality disorders (PDs). Given the frequent comorbidity between SUD and cluster B PD, it might be questioned whether the decision-making impairments typically reported in SUD populations reflect the addictive disorder, the cluster B PD, or a combination of the 2. METHODS: In the current study, we compare the decision-making performance of non-substance-abusing controls (n=53) on the Iowa Gambling Task (IGT) with the decision-making performance of 3 abstinent alcohol-dependent samples, i.e., alcoholic patients without any PD (n=38), alcoholic patients with a cluster A or C PD (n=19), and alcoholic patients with a cluster B PD (n=23). RESULTS: Overall, all 3 alcohol-dependent subsamples performed inferior compared with controls. Between alcoholic subsamples, the alcoholic patients with a cluster A or C PD had the highest IGT score, followed by the alcoholic patients without a PD, while the cluster B alcoholic patients were the most impaired. CONCLUSION: These findings suggest that impairments in decision making underlie both alcohol dependence and cluster B PD, and alcoholic patients with a comorbid cluster B PD are particularly impaired in their decision making. These deficits may underlie the severe problems that characterize cluster B alcoholic patients specifically in inappropriate behaviors (e.g., poly substance abuse, legal, and professional dysfunction).     

Alcoholism and Occupations: A Review and Analysis of 104 Occupations

A review of the many attempts to establish an association between occupations and alcoholism reveals that most do not deal with data about clinically defined alcoholism but instead use data about cirrhosis mortality, self-reported alcohol problems, and frequent and heavy drinking. The present study establishes an association between occupations and diagnoses of Alcohol Dependence Disorder and Alcohol Abuse Disorder, using data from a large population-based household interview study. Statistical adjustment using logistic methods reveals that apparent associations between occupations and alcohol-related disorders previously reported in the literature are due to characteristics of those employed in various occupations. The prevalence of alcohol dependence and abuse in two high risk industries, construction and transportation, is confirmed. More than one in four construction laborers and one in five skilled construction trades workers received a DIS/DSM-III diagnosis related to alcohol abuse. In the transportation industry one in six heavy truck drivers and material movers received an alcohol diagnosis. Analyses of the data from individuals currently employed and not employed in their occupation reveals reduction in risk for those who leave some occupations and increased risk for those who leave other occupations. Evidence is presented that employment in some occupations may be protective for Alcohol Dependence. The findings support the view that occupation may be associated with Alcohol Dependence and Alcohol Abuse independent of demographic variations. Previously proposed explanatory models for associations between occupations and alcohol problems are called into question because they do not take into account the demographic characteristics and employment status of workers.     

Epidemiology of Alcohol Abuse and Dependence in Rural Chinese Men

Background:  Several national and regional epidemiological studies in China have reported increases in the prevalence of alcohol use disorders over the past 3 decades.
Methods:  This cross-sectional study conducted in 2007 identified 11,884 male subjects aged 18 to 60 years using multi-stage randomized cluster sampling methods in 2 rural communities in China and interviewed 9,866 of them. Current and lifetime alcohol use disorders were assessed with a semi-structured diagnostic interview.
Results:  The age-standardized prevalence of current (lifetime) alcohol abuse and alcohol dependence in Hunan were 1.8% (4.8%) and 4.7% (8.6%) respectively, and those in Henan were 7.6% (11.8%) and 8.7% (10.8%). Higher age (55 to 60) and lower education were risk factors for alcohol dependence in Hunan while middle age (35 to 44), currently married, and higher education and higher income were risk factors in Henan.
Conclusions:  Alcohol abuse and dependence are no longer uncommon disorders among rural men in China. Unlike most western reports, alcohol dependence shows higher prevalence than abuse. There are significant differences in the prevalence of alcohol use disorders and the socio-demographic profile of affected individuals in the 2 different regions of the country.     

Sleep electroencephalographic spectral power after withdrawal from alcohol in alcohol-dependent patients

BACKGROUND: Dysfunctional hyperarousal is suspected to be a neurophysiological determinant of relapse in abstinent alcohol-dependent patients. In the present study, we used spectral power analysis of the sleep electroencephalographic (EEG) to quantify brain activity during sleep in patients during subacute withdrawal as well as in control subjects. Our hypothesis was that the subgroup of patients who relapsed within the 3 months to follow-up would exhibit-increased dysfunctional arousal manifested by higher-frequency (beta) EEG power during sleep. METHODS: Twenty-six alcohol-dependent in-patients were examined with polysomnography over 2 nights 2 to 3 weeks after withdrawal. At the 3-month clinical follow-up assessment, 12 of them had relapsed and 14 abstained. The control group consisted of 23 healthy subjects similar to the patients with alcohol dependence in age and gender distribution. Spectral sleep EEG analysis was performed on both nights (adaptation and baseline) of all subjects. Logarithmic artifact-controlled spectral band power of sleep stage 2 and rapid eye movement (REM) sleep was analyzed for Group, Gender, and Age effects using multiple analyses of covariance. Three groups were compared with the Group factor: relapsers, abstainers, and controls. RESULTS: Generally, both Group and Age effects were significant for the second, baseline night for the visually scored sleep parameters, while spectral EEG parameters showed significant differences in the adaptation night. In the adaptation night, a significant enhancement in the beta2 band (24-32 Hz) was seen in REM sleep in relapsers relative to both abstainers and controls. CONCLUSIONS: The beta2 increase could be interpreted as a sign of dysfunctional arousal during REM sleep "unmasked" by the additional stressor of sleep environment adaptation. Its determinants are likely to be both premorbid and drinking history related.     

Sex Differences in the Sources of Genetic Liability to Alcohol Abuse and Dependence in a Population-Based Sample of U.S. Twins

BACKGROUND: There are substantial sex differences in all levels of alcohol involvement among U.S. adults. The goal of this study was to test whether the magnitude and sources of genetic and environmental influences on liability for alcohol abuse and dependence differ for men and women. METHODS: Structured personal interviews were used to assess DSM-III-R- and DSM-IV-defined alcohol abuse and dependence among 5091 male and 4168 female twins (including 1546 identical, 1128 same-sex fraternal, and 1423 opposite-sex pairs) born in Virginia between 1934 and 1974. Twin correlations were analyzed using structural equation modeling. RESULTS: The magnitude of twin-pair resemblance was similar across several definitions of alcoholism and was substantially higher among identical than fraternal pairs. The proportion of population variation in liability attributed to genetic factors was substantial among both women (55-66%) and men (51-56%), and we found little evidence of a role of environmental factors shared by family members. In all definitions studied, we could reject a model that the genetic sources of liability in the two sexes overlap completely. CONCLUSION: In this first population-based study of alcoholism among male and female twins from the U.S., we found that genetic factors play a major role in the development of alcoholism in both sexes, that the magnitudes of genetic influence were equally high for men and women, and that the genetic sources of vulnerability are partially, but not completely, overlapping in men and women.     

Nosological Comparisons of DSM-III-R and DSM-IV Alcohol Abuse and Dependence in a Clinical Facility:Comparison with the 1988 National Health Interview Survey Results

The purpose of this study was to compare DSM-III-R and proposed formulations of DSM-IV diagnoses of alcohol use disorders in a clinical sample with the same assessment methods used in a large national survey previously reported. Issues included the number of symptoms required for abuse and dependence diagnoses, the effects of requiring evidence of physiological dependence to make the dependence diagnosis (Option 1 vs. Option 2), whether to require a duration criterion, and the concept of alcohol abuse. The diagnostic criteria proposed in the 1991 DSM-IV options book were the criteria investigated in this study. Concordance between DSM-III-R and DSM-IV was closest when the form of DSM-IV used was most similar to DSM-III-R. The duration criterion had much less effect on a dependence diagnosis in this clinical sample than in the general population. DSM-IV Option 2 for alcohol dependence excluded a number of cases from the dependence diagnosis who received such a diagnosis under DSM-III-R and DSM-IV Option 1. Abuse continued to function as a residual category, especially noticeable under increasingly restrictive definitions of dependence, and was rare in both the clinical and general population sample. Implications of the findings for research and other purposes are discussed.     

A double-blind, placebo-controlled trial to assess the efficacy of quetiapine fumarate XR in very heavy-drinking alcohol-dependent patients

Background: Despite advances in developing medications to treat alcohol dependence, few such medications have been approved by the Food and Drug Administration. Identified molecular targets are encouraging and can lead to the development and testing of new compounds. Atypical antipsychotic medications have been explored with varying results. Prior research suggests that the antipsychotic quetiapine may be beneficial in an alcohol‐dependent population of very heavy drinkers. Methods: In this double‐blind, placebo‐controlled trial, 224 alcohol‐dependent patients who reported very heavy drinking were recruited across 5 clinical sites. Patients received either quetiapine or placebo and Medical Management behavioral intervention. Patients were stratified on gender, clinical site, and reduction in drinking prior to randomization. Results: No differences between the quetiapine and placebo groups were detected in the primary outcome, percentage heavy‐drinking days, or other drinking outcomes. Quetiapine significantly reduced depressive symptoms and improved sleep but had no effect on other nondrinking outcomes. Results from a subgroup analysis suggest that patients who reduced their drinking prior to randomization had significantly better drinking outcomes during the maintenance phase (p < 0.0001). No significant interactions, however, were observed between reducer status and treatment group. Finally, quetiapine was generally well tolerated. Statistically significant adverse events that were more common with quetiapine versus placebo include dizziness (14 vs. 4%), dry mouth (32 vs. 9%), dyspepsia (13 vs. 2%), increased appetite (11 vs. 1%), sedation (15 vs. 3%), and somnolence (34 vs. 9%). Conclusions: This multisite clinical trial showed no efficacy for quetiapine compared with placebo at reducing alcohol consumption in heavy‐drinking alcohol‐dependent patients.     

Development of a Screening Questionnaire for the General Hospital and General Practices

The purpose of this study was to develop a sensitive as well as brief screening questionnaire by combining the well-known instruments CAGE and the Michigan Alcoholism Screening Test (MAST) in detecting patients with alcohol dependence or abuse in general hospitals and general practices. The number of items was reduced by means of logistic regression and item analysis based on data of 1, 167 consecutive admissions of a general hospital who completed both questionnaires. Further data were derived from a sample of 774 patients from 10 randomly selected general practices. A solution with nine items was validated in a second sample of 436 hospital inpatients. In all three samples, cases screening positive were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry to provide ICD-10 and DSM-Ill-R or DSM-IV diagnosis. In addition, 103 subjects with negative screening results were interviewed in the second general hospital sample. On grounds of the data of all three samples, a solution of seven items was chosen. This instrument comprises two CAGE and five MAST questions (Luebeck Alcohol Dependence and Abuse Screening Test; LAST) and was significantly higher in sensitivity than CAGE and SMAST. Data were robust in all three samples. It is concluded that the LAST is an optimized instrument for use in general hospital and general practice.     

Prevalence and clinical characteristics of insomnia and its subtypes in the Korean elderly

BackgroundInsomnia is known to be associated with psychiatric disorders, other sleep disorders and medical conditions, but the prevalence of insomnia diagnosis has never been estimated according to its subtypes. We studied the prevalence and clinical characteristics of insomnia diagnosis and its subtypes in the Korean elderly population.MethodsAmong 1423 sampled elderly individuals aged 60 years or older, 881 subjects participated in this study. The Athens Insomnia Scale was applied to detect insomnia symptoms, and insomnia diagnosis was finally evaluated using the international classification of sleep disorders, 2nd edition. To define insomnia subtypes, the DSM-IV-based interview, detailed history on sleep disorders and semi-structured interview for medical conditions were performed. Subsyndromal depression was defined when depressive symptoms did not meet the criteria for depressive disorders.ResultsThe prevalence of insomnia disorder was 32.8% in all subjects, with the prevalence being significantly higher in women than in men (37.9% vs. 25.2%; p < 0.001). The prevalence of insomnia subtypes was as follows; psychophysiological insomnia (PI), 20.5%; insomnia due to mental disorder 7.2%; insomnia due to general medical conditions 2.9%; insomnia in other sleep disorders 2.2%, and insomnia due to substance use 0.2%. Among subjects with PI, subsyndromal depression was diagnosed in 53.7%.ConclusionsNearly one third of Korean elderly individuals suffer from insomnia and insomnia patients showed diverse comorbid conditions, especially depressive symptoms. By establishing insomnia subtypes, we can plan to treat comorbid conditions as well as insomnia itself.