Alcohol dependence is related to overall internalizing psychopathology load rather than to particular internalizing disorders: evidence from a national sample

Background: Alcohol dependence is more prevalent among those with any one of several anxiety or depressive (“internalizing”) disorders than among those in the general population. However, because internalizing disorders are highly intercorrelated, it is ambiguous whether alcohol dependence is related to internalizing psychopathology components that are: (i) unique to a particular internalizing disorder (“specific”); versus (ii) shared across a number of internalizing disorders (“general”). To clarify this ambiguity, we employed structural equation and logistic models to decompose the specific versus general components of internalizing psychopathology and then related these components separately to alcohol dependence. Methods: The data were based on face‐to‐face interviews of U.S. community residents collected in the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N = 43,093). Results: Both analytic approaches demonstrated that increases in the general internalizing psychopathology load are accompanied by increases in the prevalence of alcohol dependence. Once the general internalizing psychopathology load is accounted for, knowing whether a particular internalizing disorder is present or absent provides little additional information regarding the prevalence of alcohol dependence. Conclusions: The components of internalizing psychopathology that are associated with alcohol dependence are shared and cumulative among common anxiety and depressive disorders. These findings have the potential to influence clinical and scientific conceptualizations of the association between alcohol dependence and internalizing psychopathology.     

A Prospective, High-Risk Study of the Relationship between Tobacco Dependence and Alcohol Use Disorders

This study examined the extent to which tobacco dependence (TD) and alcohol use disorders (AUDs) reciprocally influenced each other in a mixed-gender sample of 452 individuals ( n = 232 biological family history of paternal alcoholism, n = 220 no first- or second-degree family history of alcoholism) who were assessed once early in their freshman year of college, ∼3 years later when many were college seniors, and ∼3 years later when many had entered or were entering the work force. AUDs were more prevalent in men than women, in individuals with a family history of alcoholism, and decreased overall with time. TD was more prevalent in those with a family history of alcoholism, showed increasing rates of use over time, and was less prevalent but more stable than AUDs. Transitional probabilities indicated that although a previous AUD or TD diagnosis increased the likelihood of being diagnosed with the other disorder at a later time, comorbid AUDs and TD did not significantly affect the likelihood of recovery from either disorder. Finally, path analysis revealed significant reciprocal relationships between AUDs and TD diagnoses (each predicting the other over time), and significant prediction of AUDs and TD by family history of alcoholism at the first and third times of assessment. Findings supported two general models of AUD/TD comorbidity: a shared vulnerability model and a reciprocal influence model.     

Comorbidity of select anxiety and affective disorders with alcohol dependence in southwest California Indians

BACKGROUND: Native Americans, overall, have the highest prevalence of alcohol dependence of any US ethnic group. In several large national surveys, alcohol dependence has been significantly associated with higher rates of anxiety and affective disorders (comorbidity). However, the frequencies of these disorders and their comorbidity with alcohol dependence in Native American populations are relatively unknown. METHODS: Demographic information and DSM-III-R diagnoses were obtained by using the Semi-Structured Assessment for the Genetics of Alcoholism developed for the Collaborative Study on the Genetics of Alcoholism from 483 Southwest California Indian adults residing on contiguous reservations. The Semi-Structured Assessment for the Genetics of Alcoholism allowed differentiation of each anxiety and affective disorder into one of three types: independent of substance use, concurrent with alcohol use, and concurrent with drug use. RESULTS: Sixty-six percent of the men and 53% of the women sampled had a lifetime diagnosis of alcohol dependence. Fourteen percent of the sample had a lifetime independent anxiety disorder, and 14% of the sample had a lifetime independent affective disorder. Alcohol- and/or drug-concurrent major depression occurred in 8%, and other alcohol- and/or drug-concurrent anxiety and affective disorders each occurred in less than 1.1% of the sample. No significant comorbidity was found between alcohol dependence and independent agoraphobia, social phobia, or major depressive disorder. CONCLUSIONS: In this Southwest California Indian sample, rates of anxiety and affective disorders were substantially similar to those reported in the National Comorbidity Survey; however, comorbidity of independent disorders with alcohol dependence was not as pervasive as in the National Comorbidity Survey. Rates of concurrent anxiety and affective disorders were low. These data support the hypothesis that despite high rates of alcohol dependence, Southwest California Indians do not have higher rates of anxiety and affective disorders or comorbidity of these disorders with alcohol dependence than those reported in large surveys of non-American Indian populations.     

Alcohol use disorders increase the risk for mechanical ventilation in medical patients

BACKGROUND: Annually, more than 300,000 patients receive mechanical ventilation in an intensive care unit in the United States. The hospital mortality for ventilated patients may approach 50%, depending on the primary diagnosis. In trauma and surgical patients, a diagnosis of alcohol use disorder (AUD) is common and is associated with a prolonged duration of mechanical ventilation. The objective of this study is to determine whether the presence of AUD and the development of alcohol withdrawal are associated with an increased use and duration of mechanical ventilation in patients with medical disorders that commonly require intensive care unit admission. METHODS: We performed a retrospective cohort study using the Nationwide Inpatient Sample, a large all-payer inpatient database representing approximately 1,000 hospitals. For the years 2002 to 2003, adult patients with 1 of the 6 most common diagnoses associated with medical intensive care unit admission were included in the study. Both univariate analysis and multivariable logistic regression were performed to determine whether AUD and alcohol withdrawal were independently associated with the use and duration of mechanical ventilation in these patients. RESULTS: There were a total 785,602 patients who fulfilled 1 of the 6 diagnoses, 26,577 (3.4%) had AUD, 3,967 (0.5%) had alcohol withdrawal, and 65,071 (8.3%) underwent mechanical ventilation (53% <96 hours, 47%> or =96 hours). Independent of the medical diagnosis, AUD was associated with an increased risk of requiring mechanical ventilation (13.7 vs 8.1%, odds ratio=1.49, 95% confidence interval [1.414; 1.574], p<0.0001) but was not associated with a prolonged duration of mechanical ventilation. However, the presence of alcohol withdrawal was associated with a longer duration of mechanical ventilation (57 vs 47%> or =96 hours, odds ratio=1.48, 95% confidence interval [1.266; 1.724], p<0.0001). CONCLUSIONS: In patients with medical diagnoses associated with intensive care unit admission, AUD increases the risk for mechanical ventilation while the development of alcohol withdrawal is associated with a longer duration of mechanical ventilation.     

Alcohol use disorders among emergency department-treated older adolescents: a new brief screen (RUFT-Cut) using the AUDIT, CAGE, CRAFFT, and RAPS-QF

BACKGROUND: Early identification of alcohol use disorders (AUD) among emergency department (ED)-treated patients is important for facilitating intervention and further evaluation outside EDs. A number of brief screening instruments have been developed for identifying patients with AUD, but it is not clear whether they are practical and perform well with older adolescents in an ED setting. This study contrasted four brief screening instruments for detecting DSM-IV-defined AUD and tested a newly developed brief screen for use among ED-treated older adolescents. METHODS: The Alcohol Use Disorders Identification Test (AUDIT), the CAGE, the CRAFFT, and a modified RAPS-QF were given to 93 alcohol-using older adolescents (55% men; aged 18-20 years) in an ED. Receiver operator characteristic analyses were used to evaluate the performance of brief screens against the criterion of a lifetime DSM-IV alcohol abuse or dependence diagnosis. RESULTS: Of existing instruments, the AUDIT had the best overall performance in identifying AUD (sensitivity, 82%; specificity, 78%). A new, shorter screening instrument composed of two AUDIT items, two CRAFFT items, and one CAGE item (RUFT-Cut) performed as well as the AUDIT (sensitivity, 82%; specificity, 78%). CONCLUSIONS: Among existing alcohol screening instruments, the AUDIT performed best for identifying ED-treated older adolescents with alcohol use disorders. The RUFT-Cut is a brief screening instrument for AUD that shows promise for identifying ED-treated older adolescents who are in need of intervention or further evaluation. Future research should focus on use of the RUFT-Cut in other settings with larger, more diverse samples of adolescents.     

ICD-10 and Proposed DSM-IV Harmful Use of Alcohol/ Alcohol Abuse and Dependence, United States 1988: A Nosological Comparison

The purpose of this study was to compare ICD-10 and the proposed DSM-IV (options 1 and 2) diagnostic criteria for harmful use/abuse and dependence in a representative sample of the United States general population. Harmful use/abuse and dependence categories were contrasted in terms of prevalence and overlap. The prevalences of DSM-IV diagnoses of alcohol abuse and dependence combined were much greater than those for the corresponding ICD-10 diagnoses. Disaggregation of the harmful use/abuse and dependence diagnoses showed that the major discrepancy between the classification systems resided between harmful use and abuse categories. The prevalence of the harmful use of alcohol was nearly nonexistent in this general population sample. Reasons for this and other discrepancies are discussed in terms of the hypothesized severity of the harmful use criteria, differences in the number of diagnostic criteria and the content of the ICD-10 and DSM-IV dependence categories, the relationship between the harmful use/abuse and dependence categories, and the impact of the duration criterion.     

Diffusion tensor measures of the corpus callosum in adolescents with adolescent onset alcohol use disorders

Background: In adults, myelination injury is associated with alcoholism. Maturation of the corpus callosum is prominent during adolescence. We hypothesized that subjects with adolescent‐onset alcohol use disorders (AUD; defined as Diagnostic and Statistical Manual of Mental Disorders‐IV alcohol dependence or abuse) would have myelination mircostructural differences compared to controls. Methods: Adolescent subjects (25 males, 7 females) with an AUD (16.9 ± 1.2 years), who were recruited from substance abuse treatment programs and had co‐morbid mental disorders, and 28 sociodemographically similar healthy controls (17 males, 11 females; 15.9 ± 1.1 years) underwent a 3.0 T MRI diffusion tensor imaging scan. Results: Measures of rostral body fractional anisotropy (FA) were higher in the AUD group than in the control group. Compared to controls, mean diffusivity (MD) was lower, while FA was higher, in the AUD group in the isthmus region. Anterior corpus callosum mircostructural development differed in adolescents with AUD, as age was positively (not negatively) associated with rostrum MD and age was negatively (not positively) associated with rostrum FA. There were sex by group interactions in that control females had higher posterior midbody FA when compared to female adolescents with AUD. Conclusions: Lower MD and higher FA values in the AUD group suggest pre‐morbid vulnerability for accelerated prefrontal and temporo‐parietal myelin maturation that may enhance the risk for adolescent AUD. Significant (and opposite to developmentally expected) correlations were seen between anterior corpus callosum MD and FA measures and age in the AUD group, suggesting neurotoxic effects of alcohol on adolescent corpus callosum microstructure. As seen in adults, female adolescents with AUD may be especially vulnerable to corpus callosum mircostructural injury. Further diffusion tensor imaging studies of corpus callosum maturation in children at familial risk for alcoholism, and in those with AUD, need to be done to elucidate these mechanisms.     

Antisocial behavioral syndromes and DSM-IV alcohol use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND: Antisocial personality disorder (ASPD), syndromal adult antisocial behavior (AABS) without conduct disorder (CD) before age 15, and CD without progression to ASPD ("CD only") are highly prevalent among adults with alcohol use disorders (AUDs). Among patients in AUD treatment, antisocial behavioral syndromes are associated with more severe AUDs and poorer treatment outcomes. Comparative data concerning associations of antisocial syndromes with clinical characteristics of AUDs and the sociodemographic and clinical correlates of these syndromes among general population adults with AUDs have not previously been available. This study examines prevalences and correlates of antisocial syndromes among adults with lifetime Diagnostic and Statistical Manual--Version IV (DSM-IV) AUDs, and describes associations of these syndromes with clinical characteristics of AUDs, in the general U.S. population. METHODS: This report is based on the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n=43,093, response rate=81%). Respondents (n=11,843) with lifetime AUDs were classified according to whether they met criteria for ASPD, AABS, "CD only," or no antisocial syndrome. Correlates of antisocial syndromes were examined using contingency table approaches and normal theory analyses of variance. Associations of antisocial syndromes with clinical characteristics of AUDs, including number of lifetime episodes, duration of longest or only episode, and alcohol consumption during period of heaviest drinking were examined using normal theory and logistic regression. RESULTS: Sociodemographic and clinical correlates of antisocial syndromes among respondents with AUDs were consistent with results from prior studies. Antisocial syndromes were significantly associated with phenomenology of AUDs, particularly ASPD with the most severe clinical presentations. Associations with AABS were similar to but more modest than those with ASPD; those with "CD only" were weaker and less consistent. Patterns of associations between antisocial syndromes and clinical characteristics of AUDs were generally similar between men and women. CONCLUSIONS: Antisocial syndromes, particularly ASPD, appear to identify a more pernicious clinical profile of AUDs among adults in the general U.S. population.     

Health problems in adolescents with alcohol use disorders: self-report, liver injury, and physical examination findings and correlates

BACKGROUND: Although adolescent alcohol consumption has been found to be positively correlated with self-reported health problems, few studies have examined other health indicators. This study compared adolescents with alcohol use disorders (AUDs) and a community reference group on self-reported health problems, serum liver enzymes, and physical examination findings. The relevance of negative emotionality to understanding these health problems was also investigated. METHODS: The subjects were adolescents with AUDs recruited from clinical programs and classified as having DSM-IV alcohol dependence (n = 71) or alcohol abuse (n = 57) and reference adolescents without AUDs recruited from community sources (n = 131). The assessment of health status included self-reported health problems in 15 areas; serum liver enzyme assays, including gamma-glutamyl transpeptidase, alanine aminotransferase, and aspartate aminotransferase; and physical examination findings. Negative emotionality was determined by systematically combining scores from the Hamilton Anxiety Rating Scale, the Beck Depression Inventory, the Child Behavior Checklist, and the Multidimensional Personality Questionnaire. RESULTS: Adolescent AUDs were associated with more self-reported health problems, higher gamma-glutamyl transpeptidase and alanine aminotransferase levels, and more physical examination abnormalities. Negative emotionality was highly correlated with self-reported health problems, mediated the relationship between AUDs and self-reported health problems, and was not correlated with serum liver enzyme levels or physical examination abnormalities. CONCLUSIONS: These results indicated that AUDs during adolescence were associated with health problems, including modest but demonstrable liver injury. Self-reported health problems were probably best understood, in this context, as a negative emotionality manifestation.     

Serotonin, impulsivity, and alcohol use disorders in the older adolescent: a psychobiological study

BACKGROUND: Alcohol use disorders (AUDs) among adolescents are associated with a high prevalence of conduct disorder (CD), much as type II alcoholism in adults is associated with impulsive-aggressive behavior and antisocial personality traits. Adults with impulsive personality disorders and AUD demonstrate diminished central serotonergic responsiveness to serotonergic agonists. Dysregulation of central serotonergic function may contribute to a vulnerability to impulsive-aggressive behavior, CD, and AUD. We studied older adolescents, both male and female, to examine the relationships between sex, dispositional impulsivity, aggressivity, CD, and responsiveness to serotonergic challenge with d,l fenfluramine (FEN) early in the development of AUD. METHODS: Thirty-six adolescents between the ages of 16 and 21 years were assessed for DSM-IV AUD and other Axis I disorders by using the Psychoactive Substance Use Disorders section of the Structured Clinical Interview for DSM III-R, the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version, and CD interviews. Impulsivity and aggressivity were assessed by the Barratt Impulsiveness Scale, Lifetime History of Aggression, Buss-Durkee Hostility Inventory, Eysenck Impulsiveness Questionnaire, Youth Self Report, and Multidimensional Personality Questionnaires. FEN was administered as 0.8 mg/kg to a maximum of 60 mg, and blood was sampled at fixed intervals for prolactin, cortisol, fenfluramine, and norfenfluramine levels. RESULTS: Eighteen adolescents (12 male, 6 female) with AUD scored significantly higher on all measures of impulsivity and aggressivity compared with 18 healthy controls (12 male, 6 female). There were no significant differences between groups in peak prolactin or cortisol responses (minus baseline), or area-under-the-curve determinations (AUC); however, 9 subjects with AUD and comorbid CD had significantly elevated cortisol AUC levels compared with subjects with AUD and no CD or with normal controls. In the total sample, cortisol AUC was associated positively with measures of aggression. CONCLUSIONS: Adolescents with early-onset AUD are characterized by impulsivity and aggressivity compared with healthy peers but do not demonstrate the diminished prolactin or cortisol responses to FEN characteristic of adult alcoholics with impulsive-aggression.     

Heavy drinking, alcohol dependence, and injuries at work among young workers in the United States labor force

BACKGROUND: To determine whether heavily drinking and alcohol-dependent workers are at higher risk of occupational injury, we analyzed the nationally representative cohort of people enrolled in the National Longitudinal Survey of Youth since 1979. METHODS: This analysis was restricted to the 8569 respondents in the 1989 annual interview (age 24-32) who were employed during the 6 months before the interview. We studied occupational injuries (excluding sprains or strains) reported within 6 months of the interview in 1989 (cross-sectional analysis) and 1990 (prospective analysis). RESULTS: Among current drinkers, significant two-fold increases in the odds of injury for one or more episodes of heavy drinking were reduced to an odds ratio (OR) of 1.2 (95% confidence interval [CI] = 0.7, 2.1) in the cross-sectional analysis and an OR of 1.6 (CI 1.0, 2.8) in the prospective analysis after adjustment for confounding. No dose-response relationship with the frequency of heavy drinking was found. Alcohol-dependent respondents were not at higher risk of injury in the cross-sectional (OR = 1.1, CI 0.7, 1.8) or prospective (OR = 1.3,CI 0.8, 2.2) analyses after adjustment for confounding. CONCLUSIONS: For young U.S. workers, common occupational injuries (excluding sprains and strains) may not be strongly associated with alcohol dependence. Confounding by other risk factors may explain much of the association between being a heavy drinker and occupational injuries in this population.     

The contribution of parental alcohol use disorders and other psychiatric illness to the risk of alcohol use disorders in the offspring

Background: Few population‐based studies have investigated associations between parental history of alcoholism and the risk of alcoholism in offspring. The aim was to investigate in a large cohort the risk of alcohol use disorders (AUD) in the offspring of parents with or without AUD and with or without hospitalization for other psychiatric disorder (OPD). Methods: Longitudinal birth cohort study included 7,177 men and women born in Copenhagen between October 1959 and December 1961. Cases of AUD were identified in 3 Danish health registers and cases of OPD in the Danish Psychiatric Central Register. Offspring registration with AUD was analyzed in relation to parental registration with AUD and OPD. Covariates were offspring gender and parental social status. Results: Both maternal and paternal registration with AUD significantly predicted offspring risk of AUD (odds ratios 1.96; 95% CI 1.42 to 2.71 and 1.99; 95% CI 1.54 to 2.68, respectively). The association between maternal, but not paternal, OPD and offspring AUD was also significant (odds ratios 1.46; 95% CI 1.15 to 1.86 and 1.26; 95% CI 0.95 to 1.66, respectively). Other predictors were male gender and parental social status. A significant interaction was observed between paternal AUD and offspring gender on offspring AUD, and stratified analyses showed particularly strong associations of both paternal and maternal AUD with offspring AUD in female cohort members. Conclusions: Parental AUD was associated with an increased risk of offspring AUD independent of other significant predictors, such as gender, parental social status, and parental psychiatric hospitalization with other diagnoses. Furthermore, this association appeared to be stronger among female than male offspring. The results suggest that inherited factors related to alcoholism are at least as important in determining the risk of alcoholism among daughters as among sons.