Risk of All-Cause Mortality in Alcohol-Dependent Individuals: A Systematic Literature Review and Meta-Analysis

Area-Level Social Determinants of Alcohol-Related Mortality: Knowledge Gaps and Implications for Community Health

PURPOSE

Rates of alcohol-related mortality (including deaths attributed to chronic alcohol use as well as acute causes involving alcohol) have been increasing in the United States, particularly for certain population subgroups, such as women. This review summarizes associations of area-level social determinants of health with alcohol-related mortality. These determinants, measured at the community, county, or state level, include alcohol control policies, health care availability, and a community's socioeconomic environment. Examining multiple geographic levels illuminates how macro-level social determinants and local contexts contribute to alcohol-related mortality to inform intervention. Attention to the broad variety of social determinants of alcohol-related mortality could ultimately improve community health.

SEARCH METHODS

A literature search of three databases-PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)-conducted between March 13 and May 16, 2023, identified peer-reviewed studies published from 1990 to May 2023 that modeled at least one area-level social determinant of health as a predictor or correlate of area-level rates of alcohol-related mortality in the United States. Unpublished dissertations, commentaries, editorials, review papers, and articles published in languages other than English were excluded. Two team members reviewed each abstract to verify that the article addressed alcohol-related mortality and included at least one area-level social determinant of health.

SEARCH RESULTS

The authors screened 313 abstracts and excluded 210 that did not meet inclusion criteria. The full texts of 103 articles were retrieved. Upon further screening, 30 articles were excluded (two were not obtained), leaving 71 studies for detailed review.

DISCUSSION AND CONCLUSIONS

Many studies analyzed fatal alcohol-related motor vehicle crashes or cirrhosis/liver disease mortality. Fewer analyzed other mortality causes related to chronic alcohol consumption. No studies focused on racism and discrimination, community-level prevention activities, or community social services in relation to alcohol-related mortality. Few studies examined major health policy changes or addressed health care system factors. Although the variation across studies complicates systematic comparison of the results, some key themes did emerge from the reviewed studies, such as the beneficial effects of stronger alcohol policies and the importance of socioeconomic conditions as determinants of alcohol-related mortality. Research using a more diverse set of theoretically informed social determinants may help examine whether, how, and for whom racism and discrimination as well as health policies and social services impact alcohol-related mortality. Finally, there is a gap in research linking local community contexts with alcohol-related mortality. Better understanding of subgroup differences, interactions between different contextual factors, and specific mechanisms of action may help identify promising new strategies to improve population health and reduce alcohol-related mortality.

The prognostic impact of psychiatric intervention on alcohol-associated liver disease: The UK Biobank cohort study

BACKGROUND/AIMS

Alcohol-associated liver disease (ALD) is a public health concern. ALD patients often have psychiatric comorbidities, but the effects of psychiatric interventions on ALD are not well-established. This study explores the prognostic impact of psychiatric intervention on ALD within UK Biobank cohort.

METHODS

This population-based study included 2,417 ALD patients from the UK Biobank cohort. Psychiatric intervention was defined by a consultation with psychiatrists during hospitalization or a history of medication related to alcohol use disorder and psychiatric comorbidities. Survival analysis was conducted, incorporating propensity score matching (PSM), to precisely assess the impact of psychiatric intervention.

RESULTS

Among 2,417 ALD patients, those with F10 (mental disorders due to alcohol) codes had poorer survival outcomes. Psychiatric intervention significantly improved the outcomes of both all-cause and liver-related mortality and reduced the incidence of liver cirrhosis. In subgroup or 2-year landmark analyses, psychiatric intervention consistently showed a survival benefit in ALD patients. In the multivariate analysis, psychiatric intervention was identified as a favorable prognostic factor (hazard ratio, 0.780; P=0.002 after PSM).

CONCLUSION

This study demonstrates the favorable effect of psychiatric intervention in ALD patients with psychiatric comorbidities. These findings emphasize the importance of integrated management for ALD patients to address both their medical and psychiatric aspects. Therefore, we suggest the potential benefits of early psychiatric interventions in improving survival outcomes in ALD.

Effectiveness of psychosocial interventions for alcohol use disorder: a systematic review and meta-analysis update

Background: Given the accumulating research, evolving psychosocial treatment, and equivocal findings, updating WHO's Mental Health Gap Action Programme-2015 was necessary to ensure guidelines reflect effective strategies for alcohol use disorder (AUD).Objective: To estimate the effects of psychosocial interventions on drinking and related outcomes.Methods: We included randomized controlled trials published between January 2015 and June 2022 on adults with alcohol dependence (ICD 10/DSM-IV) and moderate to severe AUD (DSM-5), and those examined psychosocial interventions against treatment-as-usual (TAU) and active controls. Eight databases and registries were searched. Relative Risk (RR) and standardized mean difference (SMD) were used for dichotomous and continuous outcomes. We used Cochrane's risk of bias assessment (RoB2).Results: Of 873 screened records, 14 and 13 studies in the narrative synthesis and meta-analysis. Of the 2,575 participants, 71.5% were men. Thirteen studies used ICD 10/DSM IV diagnosis. Compared to TAU, any psychosocial intervention increased the relative risk of abstinence by 28% [N = 7, RR = 1.28, 95% CI: 1.07 to 1.53, p = .01, NNT = 9]. There were minimal heterogeneity and no evidence of publication bias. Psychosocial interventions were not effective in reducing the drinking frequency (n = 2, Hedge's g = -0.10, 95% CI: -0.46 to 0.26, p = .57) and drinks/drinking days (N = 5, g = -0.10, 95% CI: -0.37 to 0.16, p = .43). Treatment discontinuation did not differ between intervention and control groups [RR = 1.09, 95% CI: 0.66 to 1.80].Conclusion: Psychosocial interventions are effective in improving abstinence but not in reducing drinking frequency or amount. Policymakers must consider this evidence to generate AUD treatment guidelines.Registration: PROSPERO 2022 CRD42022342608.

Behavioural self-control training versus motivational enhancement therapy for individuals with alcohol use disorder with a goal of controlled drinking: A randomized controlled trial

BACKGROUND AND AIMS

Controlled drinking (CD) is an attractive treatment goal for a large proportion of individuals with alcohol use disorder (AUD), but the availability of treatment methods supporting a goal of CD is scarce. We tested if behavioural self-control training (BSCT) was superior to motivational enhancement therapy (MET) for individuals with AUD with a treatment goal of CD.

DESIGN

Randomized controlled two-group trial. Follow-ups were conducted at 12 and 26 weeks (primary end-point) after inclusion.

SETTING

Three specialized dependency care clinics in Stockholm, Sweden.

PARTICIPANTS

Two hundred and fifty self-referred adults (52% men) fulfilling criteria of AUD (DSM-5) and a stated treatment goal of CD.

INTERVENTION AND COMPARATOR

BSCT (n = 125), a five-session treatment based on cognitive behavioural therapy versus the active comparator, MET (n = 125), containing four sessions based on Motivational Interviewing.

MEASUREMENTS

Primary outcome measure was mean weekly alcohol consumption at the 26-week follow-up, adjusted for baseline consumption.

CONCLUSIONS

A randomized controlled trial found no evidence of a difference between behavioural self-control training and motivational enhancement therapy in reducing weekly alcohol consumption. Both groups substantially reduced consumption and behavioural self-control training was superior in reducing hazardous drinking.

Impaired health-related quality of life in the HCV cure era: who is concerned? (ANRS CO22 HEPATHER French cohort)

PURPOSE

Hepatitis C virus (HCV) cure after treatment with direct-acting antivirals (DAAs) can improve health-related quality of life (HRQoL). However, specific groups with chronic HCV may still exhibit worse post-cure HRQoL because of persisting severe liver fibrosis or social vulnerability factors (e.g. unhealthy alcohol use, living in poverty). We assessed the effect of such factors on longitudinal measures of HRQoL in chronic HCV patients.

METHODS

ANRS CO22 HEPATHER is a prospective cohort of chronic HCV patients receiving DAAs, which included notably patients with social vulnerability factors, a population usually under-represented in clinical trials. Multivariable mixed-effects linear regression models helped identify factors associated with longitudinal measures of HRQoL (PROQOL-HCV scores).

RESULTS

At enrolment, 52.4% of the 2740 participants were men, median age was 56 years [interquartile range 50-64], and 21.5% had severe liver fibrosis (FIB-4 > 3.25). Twenty-eight per cent reported current or past unhealthy alcohol use [> 2(3) alcohol units per day for women (men)], and 28.1% were living in poverty (standard of living under 1015€/month per household consumption unit). At first PROQOL-HCV completion, 54.0% of patients were HCV-cured. After multivariable adjustment, people with current or past unhealthy alcohol use, individuals living in poverty, those with severe liver fibrosis, and women had worse HRQoL in the dimensions explored. Conversely, HCV cure was associated with better HRQoL.

CONCLUSIONS

Specific socially vulnerable groups of patients with chronic HCV infection still experience impaired HRQoL, independently of HCV cure. Patient-centred interventions, including social support and referral for comorbidities, should be prioritized for them. Trial registration with ClinicalTrials.gov NCT01953458.

Mortality and alcohol-related morbidity in patients with delirium tremens, alcohol withdrawal state or alcohol dependence in Norway: A register-based prospective cohort study

BACKGROUND AND AIMS

Little is known about long-term consequences of delirium tremens (DT). This study aimed to compare all-cause and cause-specific mortality and alcohol-related morbidity between patients with: (i) DT, (ii) alcohol withdrawal state (AWS) and (iii) alcohol dependence (AD).

DESIGN

A national longitudinal health registry study with linked data from the Norwegian Patient Registry and the Norwegian Cause of Death Registry.

SETTING

Norway.

PARTICIPANTS

All patients registered in the Norwegian Patient Registry between 2009 and 2015 with a diagnosis of AD (ICD-10 code F10.2), AWS (F10.3) or DT (F10.4) and aged 20-79 years were included (n = 36 287).

MEASUREMENTS

Patients were categorized into three mutually exclusive groups; those with DT diagnosis were categorized as DT patients regardless of whether or not they had received another alcohol use disorder diagnosis during the observation period or not. Outcome measures were: annual mortality rate, standardized mortality ratios (SMR) for all-cause and cause-specific mortality and proportion of alcohol-related morbidities which were registered in the period from 2 years before to 1 year after the index diagnosis.

FINDINGS

DT patients had higher annual mortality rate (8.0%) than AWS (5.0%) and AD (3.6%) patients, respectively. DT patients had higher mortality [SMR = 9.8, 95% confidence interval (CI) = 8.9-10.7] than AD patients (SMR = 7.0, 95% CI = 6.8-7.2) and AWS patients (SMR = 7.8, 95% CI = 7.2-8.4). SMR was particularly elevated for unnatural causes of death, and more so for DT patients (SMR = 26.9, 95% CI = 21.7-33.4) than for AD patients (SMR = 15.2, 95% CI = 14.2-16.3) or AWS patients (SMR = 20.1, 95% CI = 16.9-23.9). For all comorbidities, we observed a higher proportion among DT patients than among AWS or AD patients (P < 0.001).

CONCLUSIONS

People treated for delirium tremens appear to have higher rates of mortality and comorbidity than people with other alcohol use disorders.

All-cause and cause-specific mortality in individuals with an alcohol-related emergency or hospital inpatient presentation: A retrospective data linkage cohort study

BACKGROUND AND AIMS

Alcohol consumption is a leading risk factor for premature mortality globally, but there are limited studies of broader cohorts of people presenting with alcohol-related problems outside of alcohol treatment services. We used linked health administrative data to estimate all-cause and cause-specific mortality among individuals who had an alcohol-related hospital inpatient or emergency department presentation.

DESIGN

Observational study using data from the Data linkage Alcohol Cohort Study (DACS), a state-wide retrospective cohort of individuals with an alcohol-related hospital inpatient or emergency department presentation.

SETTING

Hospital inpatient or emergency department presentation in New South Wales, Australia, between 2005 and 2014.

PARTICIPANTS

Participants comprised 188 770 individuals aged 12 and above, 66% males, median age 39 years at index presentation.

MEASUREMENTS

All-cause mortality was estimated up to 2015 and cause-specific mortality (by those attributable to alcohol and by specific cause of death groups) up to 2013 due to data availability. Age-specific and age-sex-specific crude mortality rates (CMRs) were estimated, and standardized mortality ratios (SMRs) were calculated using sex and age-specific deaths rates from the NSW population.

FINDINGS

There were 188 770 individuals in the cohort (1 079 249 person-years of observation); 27 855 deaths were recorded (14.8% of the cohort), with a CMR of 25.8 [95% confidence interval (CI) = 25.5, 26.1] per 1000 person-years and SMR of 6.2 (95% CI = 5.4, 7.2). Mortality in the cohort was consistently higher than the general population in all adult age groups and in both sexes. The greatest excess mortality was from mental and behavioural disorders due to alcohol use (SMR = 46.7, 95% CI = 41.4, 52.7), liver cirrhosis (SMR = 39.0, 95% CI = 35.5, 42.9), viral hepatitis (SMR = 29.4, 95% CI = 24.6, 35.2), pancreatic diseases (SMR = 23.8, 95% CI = 17.9, 31.5) and liver cancer (SMR = 18.3, 95% CI = 14.8, 22.5). There were distinct differences between the sexes in causes of excess mortality (all causes fully attributable to alcohol female versus male risk ratio = 2.5 (95% CI = 2.0, 3.1).

CONCLUSIONS

In New South Wales, Australia, people who came in contact with an emergency department or hospital for an alcohol-related presentation between 2005 and 2014 were at higher risk of mortality than the general New South Wales population during the same period.

Prediction of chronological age and its applications in forensic casework: methods, current practices, and future perspectives

Estimating an individual's age can be relevant in several areas primarily related to the clinical and forensic fields. In the latter, estimation of an individual's chronological age from biological material left by the perpetrator at a crime scene may provide helpful information for police investigation. Estimation of age is also beneficial in immigration cases, where age can affect the person's protection status under the law, or in disaster victim identification to narrow the list of potential missing persons. In the last decade, research has focused on establishing new approaches for age prediction in the forensic field. From the first forensic age estimations based on morphological inspections of macroscopic changes in bone and teeth, the focus has shifted to molecular methods for age estimation. These methods allow the use of samples from human biological material that does not contain morphological age features and can, in theory, be investigated in traces containing only small amounts of biological material. Molecular methods involving DNA analyses are the primary choice and estimation of DNA methylation levels at specific sites in the genome is the most promising tool. This review aims to provide an overview of the status of forensic age prediction using molecular methods, with particular focus in DNA methylation. The frequent challenges that impact forensic age prediction model development will be addressed, together with the importance of validation efforts within the forensic community.

Extra-hepatic morbidity and mortality in alcohol-related liver disease: Systematic review and meta-analysis

BACKGROUND

Alcohol use increases the risk of many conditions in addition to liver disease; patients with alcohol-related liver disease (ALD) are therefore at risk from both extra-hepatic and hepatic disease.

AIMS

This review synthesises information about non-liver-related mortality in persons with ALD.

METHODS

A systematic literature review was performed to identify studies describing non-liver outcomes in ALD. Information about overall non-liver mortality was extracted from included studies and sub-categorised into major causes: cardiovascular disease (CVD), non-liver cancer and infection. Single-proportion meta-analysis was done to calculate incidence rates (events/1000 patient-years) and relative risks (RR) compared with control populations.

RESULTS

Thirty-seven studies describing 50 302 individuals with 155 820 patient-years of follow-up were included. Diabetes, CVD and obesity were highly prevalent amongst included patients (5.4%, 10.4% and 20.8% respectively). Outcomes varied across the spectrum of ALD: in alcohol-related fatty liver the rate of non-liver mortality was 43.4/1000 patient-years, whereas in alcoholic hepatitis the rate of non-liver mortality was 22.5/1000 patient-years. The risk of all studied outcomes was higher in ALD compared with control populations: The RR of death from CVD was 2.4 (1.6-3.8), from non-hepatic cancer 2.2 (1.6-2.9) and from infection 8.2 (4.7-14.3).

CONCLUSION

Persons with ALD are at high risk of death from non-liver causes such as cardiovascular disease and non-hepatic cancer.

Severity of alcohol dependence and mortality after 20 years in an adult general population sample

OBJECTIVES

To estimate mortality on grounds of the severity of alcohol dependence which has been assessed by two approaches: the frequency of alcohol dependence symptoms (FADS) and the number of alcohol dependence criteria (NADC).

METHODS

A random sample of adult community residents in northern Germany at age 18 to 64 had been interviewed in 1996. Among 4075 study participants at baseline, for 4028 vital status was ascertained 20 years later. The FADS was assessed by the Severity of Alcohol Dependence Scale among the 780 study participants who had one or more symptoms of alcohol dependence or abuse and vital status information. The NADC was estimated by the Munich Composite International Diagnostic Interview among 4028 study participants with vital status information. Cox proportional hazard models were used.

RESULTS

The age-adjusted hazard ratio for the FADS (value range: 0-79) was 1.02 (95% confidence interval, CI: 1.016-1.028), for the NADC (value range: 0-7) it was 1.25 (CI: 1.19-1.32).

CONCLUSIONS

The FADS and NADC predicted time to death in a dose-dependent manner in this adult general population sample.

Predictors of abstinence, no heavy drinking days, and a 2-level reduction in World Health Organization drinking levels during treatment for alcohol use disorder in the COMBINE study

BACKGROUND

Data from trials of medications for alcohol use disorder (AUD) can be used to identify predictors of drinking outcomes regardless of treatment, which can inform the design of future trials with heterogeneous populations. Here, we identified predictors of abstinence, no heavy drinking days, and a 2-level reduction in World Health Organization (WHO) drinking levels during treatment for AUD in the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study.

METHODS

We utilized data from the COMBINE Study, a randomized placebo-controlled trial evaluating the efficacy of naltrexone and acamprosate, both alone and in combination, for AUD (n = 1168). A tree-based machine learning algorithm was used to construct classification trees predicting abstinence, no heavy drinking days, and a 2-level reduction in WHO drinking levels in the last 4 weeks of treatment, based on 89 baseline variables.

RESULTS

The final tree for predicting abstinence had one split based on consecutive days abstinent prior to randomization, with a higher proportion of subjects achieving abstinence among those classified as abstinent for >2 versus ≤2 consecutive weeks prior to randomization (66% vs. 29%). The final tree for predicting no heavy drinking days in the last 4 weeks of treatment had three splits based on consecutive days abstinent, age, and total Alcohol Dependence Scale score at baseline. Seventy-three percent of the subjects classified as abstinent for >2 consecutive weeks prior to randomization had no heavy drinking days in the last 4 weeks of treatment. Among those classified as abstinent ≤2 consecutive weeks prior, three additional splits showed that younger subjects (age ≤44 years; 37%), and older subjects (age >44) with a total Alcohol Dependence Scale score >13 and complete abstinence (56%) or other drinking goals (35%), were less likely to have no heavy drinking days than older subjects with a total Alcohol Dependence Scale score ≤13 (67%). The final tree for predicting a 2-level reduction in WHO levels had no splits.

CONCLUSIONS

Consecutive days abstinent prior to randomization may predict abstinence and no heavy drinking days and total Alcohol Dependence Scale score and age may predict no heavy drinking days. The 2-level reduction in WHO levels outcome may be less likely to discriminate based on multiple patient characteristics.

Alcohol-related liver disease and liver transplantation

Alcohol-related liver disease (ALD) has become the major cause of liver transplantation (LT) in Korea, and is currently the most common cause of LT in Europe and the United States. Although, ALD is one of the most common indications for LT, it is traditionally not considered as an option for patients with ALD due to organ shortages and concerns about relapse. To select patients with terminal liver disease due to ALD for transplants, most LT centers in the United States and European countries require a 6-month sober period before transplantation. However, Korea has a different social and cultural background than Western countries, and most organ transplants are made from living donors, who account for approximately twice as many procedures as deceased donors. Most LT centers in Korea do not require a specific period of sobriety before transplantation in patients with ALD. As per the literature, 8%–20% of patients resume alcohol consumption 1 year after LT, and this proportion increases to 30%–40% at 5 years post-LT, among which 10%–15% of patients resume heavy drinking. According to previous studies, the risk factors for alcohol relapse after LT are as follows: young age, poor familial and social support, family history of alcohol use disorder, previous history of alcohol-related treatment, shorter abstinence before LT, smoking, psychiatric disorders, irregular follow-up, and unemployment. Recognition of the risk factors, early detection of alcohol consumption after LT, and regular follow-up by a multidisciplinary team are important for improving the short- and long-term outcomes of LT patients with ALD.

Provider perceptions of challenges to identifying women Veterans with hazardous substance use

BACKGROUND

Approximately one-third of women Veterans Health Administration (VHA) users have substance use disorders (SUD). Early identification of hazardous substance use in this population is critical for the prevention and treatment of SUD. We aimed to understand challenges to identifying women Veterans with hazardous substance use to improve future referral, evaluation, and treatment efforts.

METHODS

Design: We conducted a secondary analysis of semi-structured interviews conducted with VHA interdisciplinary women's SUD providers at VA Greater Los Angeles Healthcare System.

PARTICIPANTS

Using purposive and snowball sampling we interviewed 17 VHA providers from psychology, social work, women's health, primary care, and psychiatry.

APPROACH

Our analytic approach was content analysis of provider perceptions of identifying hazardous substance use in women Veterans.

RESULTS

Providers noted limitations across an array of existing identification methodologies employed to identify women with hazardous substance use and believed these limitations were abated through trusting provider-patient communication. Providers emphasized the need to have a process in place to respond to hazardous use when identified. Provider level factors, including provider bias, and patient level factors such as how they self-identify, may impact identification of women Veterans with hazardous substance use. Tailoring language to be sensitive to patient identity may help with identification in women Veterans with hazardous substance use or SUD who are not getting care in VHA but are eligible as well as those who are not eligible for care in VHA.

CONCLUSIONS

To overcome limitations of existing screening tools and processes of identifying and referring women Veterans with hazardous substance use to appropriate care, future efforts should focus on minimizing provider bias, building trust in patient-provider relationships, and accommodating patient identities.

Mortality in adult children of parents with alcohol use disorder: a nationwide register study

Research suggests that adult children of parents with harmful alcohol use are at increased risk for premature death. This national cohort study investigated mortality in adult children of parents with alcohol use disorder (AUD), adjusting for sociodemographic variables. The study used 1973 to 2018 data from Swedish national registers to compare mortality risk in children who had ≥ 1 parent with AUD (ICD-10 code F10 and its ICD-8 and ICD-9 equivalents) (n = 122,947) and those who did not (n = 2,298,532). A Cox regression model adjusted for year of birth, sex, parental education, and childhood loss of a parent was used. Before the age of 18 years, about 5% of children born in Sweden lived with ≥ 1 parent who had a clinical diagnosis of AUD. Overall mortality was higher in adult children of parents with AUD: hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.71-1.82. Mortality remained elevated after adjustments for sociodemographic factors (HR 1.45, 95% CI 1.40-1.50). Children of parents with AUD had increased mortality from all investigated causes. The highest excess risk was for death from drug-related causes (excluding accidental poisonings) (HR 3.08, 95% CI 2.74-3.46). For most causes, mortality was higher if the mother had AUD than if the father had AUD. Patterns of mortality were similar in both sexes. This study provides evidence that parental AUD raises the risk of offspring mortality from preventable causes such as drug use, suicide (HR 2.16, 95% CI 1.98-2.36), accident (HR 2.00, 95% CI 1.87-2.13), and assault (HR 1.76, 95% CI 1.38-2.24).

Effects of a minimal-guided on-line intervention for alcohol misuse in Estonia: a randomized controlled trial

BACKGROUND AND AIMS

Estonia has one of the highest alcohol-attributable mortality rates within the European Union. The aim of this study was to estimate the efficacy of an on-line self-help intervention to reduce problem drinking at the population level.

DESIGN

On-line open randomized controlled trial with an 8-week intervention and an active control group (intervention n = 303, control n = 286). Assessments took place at baseline and at 6 months follow-up.

SETTING

On- and offline channels were used for population-based recruitment within a nation-wide prevention campaign in Estonia.

PARTICIPANTS

Inclusion criteria were age ≥ 18 years, heavy drinking [Alcohol Use Disorders Identification (AUDIT) test score ≥ 8], literacy in Estonian and at least weekly access to the internet; n = 589 participants were randomized (50% male, 1% other; mean age 37.86 years; 45% with higher level of education).

INTERVENTION AND COMPARATOR

The intervention consisted of 10 modules based on principles of cognitive-behavioral therapy and motivational interviewing. The active control group received access to a website with a self-test including personalized normative feedback and information for standard alcohol treatment.

MEASUREMENTS

The primary outcome was AUDIT scores at 6 months follow-up adjusted for baseline scores.

FINDINGS

Intention-to-treat analyses were applied. Missing data were addressed by using baseline observation carried forward (BOCF) and multiple imputation by chained equations (MI); 175 completed follow-up in the intervention group and 209 in the control group. AUDIT score at follow-up was significantly smaller in the intervention [BOCF mean = 13.91, standard deviation (SD) = 7.61, MI mean = 11.03, SD = 6.55] than control group (BOCF mean = 15.30, SD = 7.31; MI mean = 14.30, SD = 7.21), with a group difference of -1.38 [95% confidence interval (CI) = -2.58, -0.18], P = 0.02 for BOCF and -3.26 (95% CI = -2.01, -4.51), P < 0.001 for MI.

CONCLUSIONS

A randomized controlled trial has found that an on-line self-help intervention with minimal guidance was effective at reducing problem drinking in Estonia.

Associations between alcohol use and accelerated biological ageing

Harmful alcohol use is a leading cause of premature death and is associated with age-related disease. Biological ageing is highly variable between individuals and may deviate from chronological ageing, suggesting that biomarkers of biological ageing (derived from DNA methylation or brain structural measures) may be clinically relevant. Here, we investigated the relationships between alcohol phenotypes and both brain and DNA methylation age estimates. First, using data from UK Biobank and Generation Scotland, we tested the association between alcohol consumption (units/week) or hazardous use (Alcohol Use Disorders Identification Test [AUDIT] scores) and accelerated brain and epigenetic ageing in 20,258 and 8051 individuals, respectively. Second, we used Mendelian randomisation (MR) to test for a causal effect of alcohol consumption levels and alcohol use disorder (AUD) on biological ageing. Alcohol use showed a consistent positive association with higher predicted brain age (AUDIT-C: β = 0.053, p = 3.16 × 10-13 ; AUDIT-P: β = 0.052, p = 1.6 × 10-13 ; total AUDIT score: β = 0.062, p = 5.52 × 10-16 ; units/week: β = 0.078, p = 2.20 × 10-16 ), and two DNA methylation-based estimates of ageing, GrimAge (units/week: β = 0.053, p = 1.48 × 10-7 ) and PhenoAge (units/week: β = 0.077, p = 2.18x10-10 ). MR analyses revealed limited evidence for a causal effect of AUD on accelerated brain ageing (β = 0.118, p = 0.044). However, this result should be interpreted cautiously as the significant effect was driven by a single genetic variant. We found no evidence for a causal effect of alcohol consumption levels on accelerated biological ageing. Future studies investigating the mechanisms associating alcohol use with accelerated biological ageing are warranted.

Harm Reduction in Health Care Settings

Harm reduction is an approach to reduce the risk of harms to an individual using substances without requiring abstinence. This review discusses substance-specific interventions for opioids, alcohol, and stimulants that can minimize harms for individuals who use these substances. Topics discussed include overdose prevention, infection prevention, and low-barrier substance use disorder treatment.

Genetic liability for substance use associated with medical comorbidities in electronic health records of African- and European-ancestry individuals

Polygenic risk scores (PRS) represent an individual's summed genetic risk for a trait and can serve as biomarkers for disease. Less is known about the utility of PRS as a means to quantify genetic risk for substance use disorders (SUDs) than for many other traits. Nonetheless, the growth of large, electronic health record-based biobanks makes it possible to evaluate the association of SUD PRS with other traits. We calculated PRS for smoking initiation, alcohol use disorder (AUD), and opioid use disorder (OUD) using summary statistics from the Million Veteran Program sample. We then tested the association of each PRS with its primary phenotype in the Penn Medicine BioBank (PMBB) using all available genotyped participants of African or European ancestry (AFR and EUR, respectively) (N = 18,612). Finally, we conducted phenome-wide association analyses (PheWAS) separately by ancestry and sex to test for associations across disease categories. Tobacco use disorder was the most common SUD in the PMBB, followed by AUD and OUD, consistent with the population prevalence of these disorders. All PRS were associated with their primary phenotype in both ancestry groups. PheWAS results yielded cross-trait associations across multiple domains, including psychiatric disorders and medical conditions. SUD PRS were associated with their primary phenotypes; however, they are not yet predictive enough to be useful diagnostically. The cross-trait associations of the SUD PRS are indicative of a broader genetic liability. Future work should extend findings to additional population groups and for other substances of abuse.

The Spectrum of Alcohol Use: Epidemiology, Diagnosis, and Treatment

In the United States, alcohol is the most common substance used and the spectrum of unhealthy alcohol use is highly prevalent. Complications of unhealthy alcohol use affect nearly every organ system. One of the most frequent and potentially life-threatening of these complications is alcohol withdrawal syndrome for which benzodiazepines remain first-line therapy. Pharmacologic treatment of alcohol use disorder, the most severe form of unhealthy alcohol use, is underutilized despite the availability of multiple effective medications. Although behavioral therapies are an important component of treatment, they are overemphasized at the expense of pharmacotherapy.

Long-Term Cost-Effectiveness of Smoking Cessation Interventions in People With Mental Disorders: A Dynamic Decision Analytical Model

OBJECTIVES

People with mental disorders are more likely to smoke than the general population. The objective of this study is to develop a decision analytical model that estimates long-term cost-effectiveness of smoking cessation interventions in this population.

METHODS

A series of Markov models were constructed to estimate average lifetime smoking-attributable inpatient cost and expected quality-adjusted life-years. The model parameters were estimated using a variety of data sources. The model incorporated uncertainty through probabilistic sensitivity analysis using Monte Carlo simulations. It also generated tables presenting incremental cost-effectiveness ratios of the proposed interventions with varying incremental costs and incremental quit rates. We used data from 2 published trials to demonstrate the model's ability to make projections beyond the observational time frame.

RESULTS

The average smoker's smoking-attributable inpatient cost was 3 times higher and health utility was 5% lower than ex-smokers. The intervention in the trial with a statistically insignificant difference in quit rate (19% vs 25%; P=.2) showed a 45% to 49% chance of being cost-effective compared with the control at willingness-to-pay thresholds of £20 000 to £30 000/quality-adjusted life-years. The second trial had a significant outcome (quit rate 35.9% vs 15.6%; P<.001), and the corresponding probability of the intervention being cost-effective was 65%.

CONCLUSIONS

This model provides a consistent platform for clinical trials to estimate the potential lifetime cost-effectiveness of smoking cessation interventions for people with mental disorders and could help commissioners direct resources to the most cost-effective programs. However, direct comparisons of results between trials must be interpreted with caution owing to their different designs and settings.

Impact of excessive alcohol abuse on age prediction using the VISAGE enhanced tool for epigenetic age estimation in blood

DNA methylation-based clocks provide the most accurate age estimates with practical implications for clinical and forensic genetics. However, the effects of external factors that may influence the estimates are poorly studied. Here, we evaluated the effect of alcohol consumption on epigenetic age prediction in a cohort of extreme alcohol abusers. Blood samples from deceased alcohol abusers and age- and sex-matched controls were analyzed using the VISAGE enhanced tool for age prediction from somatic tissues that enables examination of 44 CpGs within eight age markers. Significantly altered DNA methylation was recorded for alcohol abusers in MIR29B2CHG. This resulted in a mean predicted age of 1.4 years higher compared to the controls and this trend increased in older individuals. The association of alcohol abuse with epigenetic age acceleration, as determined by the prediction analysis performed based on MIR29B2CHG, was small but significant (β = 0.190; P-value = 0.007). However, the observed alteration in DNA methylation of MIR29B2CHG had a non-significant effect on age estimation with the VISAGE age prediction model. The mean absolute error in the alcohol-abusing cohort was 3.1 years, compared to 3.3 years in the control group. At the same time, upregulation of MIR29B2CHG expression may have a biological function, which merits further studies.

World Health Organization risk drinking levels as a treatment outcome measure in topiramate trials

BACKGROUND

Although abstinence has traditionally been considered the only suitable outcome for alcohol treatment, reduced drinking is also associated with improved functioning and medical and psychiatric outcomes. The World Health Organization (WHO) risk drinking levels (RDLs) have been shown to be valid outcome measures in treatment trials for alcohol use disorder (AUD).

METHODS

We conducted a secondary analysis of two 12-week, randomized controlled trials (RCTs), in which a total of 308 individuals with problematic alcohol use received topiramate or placebo treatment. We compared the utility of the WHO RDLs with other treatment outcomes, including self-reported measures of alcohol consumption, alcohol-related problems, and quality of life, and the biomarker gamma-glutamyltransferase.

RESULTS

Topiramate treatment was associated with small effect sizes for both a 1-level (d = 0.26) and a 2-level (d = 0.19) reduction in WHO RDL, effects that were not significant after correction for multiple comparisons. No heavy drinking days, one of the outcome measures recommended by the US Food and Drug Administration for alcohol medication registration trials, also exhibited a small effect (0.21), while an effect size for abstinence could not be calculated. There were medium effects of topiramate on continuous measures of percent heavy drinking days (d = 0.49) and alcohol-related problems (d = 0.41).

CONCLUSIONS

Topiramate is an efficacious pharmacotherapy for AUD. Although continuous measures of drinking and alcohol-related problems yielded larger effect sizes than the WHO RDLs, the latter nonetheless provide a categorical alternative for use in both clinical care and pharmacotherapy trials.

Combined analysis of the moderating effect of a GRIK1 polymorphism on the effects of topiramate for treating alcohol use disorder

BACKGROUND

In an initial study, we reported that topiramate reduced heavy drinking among individuals who sought to reduce their drinking and that the effect was moderated by a single nucleotide polymorphism (SNP; rs2832407) in GRIK1, which encodes the kainate GluK1 receptor subunit (Kranzler et al., 2014). In a subsequent study that prospectively randomized patients to medication group based on their rs2832407 genotype, we replicated the main effect of topiramate but not the moderating effect of the SNP (Kranzler et al., 2021). Given the similar design of the two studies, here we combined the findings to provide greater statistical power to test the pharmacogenetic effect.

MATERIAL AND METHODS

This secondary analysis of two 12-week, randomized controlled trials of topiramate included a total of 292 European-ancestry individuals (67.1 % male; topiramate: 48.3 %, placebo: 51.7 %) with problematic alcohol use. Using MANOVA, we examined changes in self-reported alcohol consumption, problems resulting from alcohol use, and quality of life, and the biomarker γ-glutamyltransferase. To test the pharmacogenetic hypothesis, all patients were genotyped for rs2832407.

RESULTS

There was a significant overall effect of topiramate on the alcohol-related outcomes (partial η2 = 0.134, p < 0.001), with follow-up analyses showing significant reductions in percent heavy drinking days (Cohen's d = 0.49), percent days abstinent (d = 0.23), drinks/day (d = 0.29) and alcohol-related problems (d = 0.45). Overall, the moderating effect of the SNP was non-significant (partial η² = 0.026, p = 0.37).

CONCLUSIONS

Although topiramate is an efficacious medication for reducing drinking and alcohol-related problems among patients with problematic alcohol use, rs2832407 does not appear to moderate its therapeutic effects. www.clinicaltrials.gov registrations: NCT00626925 and NCT02371889.

The association of telomere length with substance use disorders: a systematic review and meta-analysis of observational studies

BACKGROUND AND AIMS

Several recent studies have investigated the relationship between telomere length and substance use disorders with inconsistent results. We aimed to assess this association and to identify moderators of the relationship.

METHODS

Systematic review and meta-analysis. Selection criteria were observational studies reporting telomere length in people with a substance use disorder compared with a control group. Studies focused solely on nicotine addiction, employing other study designs, and non-human studies were excluded. Study selection and data extraction were independently conducted by two researchers following a standardized protocol and included studies until December 2019. Standardized mean differences were used as the effect size index [d; 95% confidence interval (CI)] and random-effects models were used for the meta-analysis. Cochran's Q-statistic, I² index, visual inspection of the forest plot and a 95% prediction interval were applied to verify study heterogeneity. Subgroup analyses and meta-regressions were conducted to explore heterogeneity. Small study effects were examined using the 'funnel plot', the Egger test, Duval & Tweedie's trim-and-fill method and the precision-effect test-precision-effect estimate with standard error (PET-PEESE) method. The risk of bias and the quality of evidence were assessed.

RESULTS

Ten studies (12 analysis units with 2671 cases and 4532 controls) met the selection criteria. An overall effect size of moderate magnitude was found (d₊  = -0.63; 95% CI = -1.00 and -0.26; P = 0.0008). A potential small study effect was detected, as well as large heterogeneity between studies (Q-statistic P < 0.001, I²  = 97.3%). Selection of controls, reporting laboratory quality control procedures and total sample size significantly affected the effect size. The quality of the evidence was very low, based on risk of bias analysis and the grading of recommendations assessment, development and evaluation (GRADE) system.

CONCLUSIONS

People with substance use disorders appear to have shorter telomere length than controls; however, this finding should be interpreted with caution due to the poor quality of the evidence.

Association of age at first drink and first alcohol intoxication as predictors of mortality: a birth cohort study

BACKGROUND

More information on the health-related repercussions of age at onset of adolescent drinking is needed. The aim of this study was to examine the associations between self-reported age at first drink and age at first alcohol intoxication with the risk of death by age 30.

METHODS

The sample (n = 6564; 49.1% males) included all participants of the Northern Finland Birth Cohort Study 1986 (NFBC1986) for whom the two measures of adolescent drinking were available. Self-reported age at onset of first drink and first alcohol intoxication were analyzed along with background variables and data regarding subsequent psychiatric diagnoses. Adolescents were dichotomized into those reporting age at first drink and age at first intoxication before or after age 14. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence interval (95% CI) for death by age 30.

RESULTS

By the age of 30, 0.7% (n = 47) of all 6564 participants were deceased. In the multivariable models, male gender and a history of illicit substance use in adolescence were associated with both all-cause mortality and mortality due to accidents or suicide. After controlling for confounding variables, age at first alcohol intoxication was associated with all-cause mortality (HR 2.33; 95% CI 1.04-5.20) as well as death due to accidents or suicide (HR 2.99; 95% CI 1.11-8.05).

CONCLUSIONS

Earlier age at first intoxication carries long-term repercussions with respect to premature loss of life. Efforts should be made targeting the prolongation of initiating binge drinking in adolescence to diminish this mortality risk.

A cascade of care for alcohol use disorder: Using 2015-2019 National Survey on Drug Use and Health data to identify gaps in past 12-month care

BACKGROUND

Although effective treatments exist, alcohol use disorder (AUD) is undertreated. We used a cascade of care framework to understand gaps in care for persons with AUD.

METHODS

Using 2015-2019 National Survey on Drug Use and Health data, we evaluated the following steps in the cascade of care: (1) adult prevalence of AUD; (2) proportion of adults with AUD who utilized health care in the past 12 months; (3) proportion with AUD screened about their alcohol use; (4) proportion with AUD who received a brief intervention about their alcohol misuse; (5) proportion with AUD who received information about treatment for alcohol misuse; and (6) proportion with AUD who received treatment. Analyses were stratified by AUD severity.

RESULTS

Of the 214,505 persons included in the sample, the weighted prevalence of AUD was 7.8% (95% CI 7.6-8.0%). Cascades of care showed the majority of individuals with AUD utilized health care in the past 12 months [81.4% (95% CI 80.7-82.1%)] and were screened about alcohol use [69.9% (95% CI 68.9-70.8%)]. However, only a minority of individuals received subsequent steps of care, including 11.6% (95% CI 11.0-12.2%) who reported receiving a brief intervention, 5.1% (95% CI 4.6-5.6%) who were referred to treatment, and 5.8% (95% CI 5.4-6.3%) who received treatment. Similar patterns were observed when cascades of care were stratified by AUD severity.

CONCLUSIONS

Persons with AUD commonly utilize health care and are often screened about alcohol use, but few receive treatment. Healthcare settings-particularly primary care settings-represent a prime opportunity to implement AUD treatment to improve outcomes in this high-risk population.

Characterization of benzodiazepine misuse and comorbidities in patients with alcohol use disorder

BACKGROUND

Due to the frequent presence of anxious symptoms and sleep disorders, benzodiazepines (BZD) are often prescribed to patients with alcohol use disorder (AUD).

OBJECTIVES

To assess BZD misuse and psychiatric comorbidities in patients with AUD.

METHODS

This prospective, monocentric study included all adult patients with AUD hospitalized in a French addiction unit for alcohol withdrawal from November 2017 to May 2018.

RESULTS

Among the 153 patients included, 75 (49%) were using BZD at the time of their hospitalization. Duration of alcohol addiction was longer in BZD users: (33 ± 27 years vs. 29 ± 11 years; P = 0.001). BZD misuse was noted in 27 patients consuming benzodiazepines (36% of BZD users and 18% of all included patients), mainly increase in the dose (on average, 3 ± 4 times the prescribed dose). The most frequently misused benzodiazepines were diazepam (43.2%), alprazolam (18.9%), and lormetazepam (13.5%). The frequency of patients with lifetime use of cocaine or heroin was higher among BZD misusers than among non-misusers (84.6% vs. 42.2%; <0.01 and 53.9% vs. 27.1%; P = 0.04). The frequency of patients consuming cocaine in the last month was higher in BZD misusers than in others: 16% versus 6%, P = 0.002. In multivariate analysis, age (OR=1.65 for 5 years, 95% CI = 1.19-2.27; P = 0.023), psychiatric comorbidities (at least one comorbidity: OR=6.03, 95% CI = 1.40-25.83; P = 0.015) and lifetime cocaine consumption (OR=4.37, 95% CI = 1.21-15.86; P = 0.025) were independently associated with BZD misuse.

CONCLUSION

BZD prescription for long periods might result in tolerance and dose increase. Educational therapy, prescribers' awareness, and development of therapeutic alternatives are essential to limit BZD misuse.

Are non-abstinent reductions in World Health Organization drinking risk level a valid treatment target for alcohol use disorders in adolescents with ADHD?

•

Changes in WHO alcohol risk level are highly variable in youth treated for ADHD/SUD.

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Achieving > 2-level reduction in WHO risk is linked to improvements in functioning.

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Achieving > 2-level reduction in WHO risk is linked to decreased ADHD symptoms.

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> 2-level reduction in WHO risk may be a valid non-abstinent AUD outcome in youth with ADHD/SUD.

Introduction

Abstinence from drinking represents the primary treatment target for alcohol use disorders (AUD) in youth, but few adolescents who engage in problematic drinking seek treatment. A reduction in World Health Organization (WHO) drinking risk level has been established as valid and reliable non-abstinent treatment target for AUD in adults but remains unstudied in youth.

Methods

The present study used data from the NIDA-CTN-0028 trial to examine associations between reductions in WHO drinking risk level and changes in global functioning and attention-deficit hyperactivity disorder (ADHD) symptoms during treatment in a sample of adolescents (ages 13–18 years) with ADHD and comorbid substance use disorder (SUD) (n = 297, 61% with AUD) receiving a 16-week intervention that combined ADHD pharmacotherapy (OROS-methylphenidate vs. placebo) and drug-focused cognitive-behavioral therapy.

Results

Shifts in drinking risk level during treatment were highly variable in adolescents treated for ADHD/SUD, and influenced by AUD diagnostic status. In the total sample, 15% of participants had a 2-level or greater reduction in WHO drinking risk level, with 59% and 24% showing no change or an increase in risk-level during treatment respectively. Achieving at least a 2-level change in WHO drinking risk level during treatment was associated with greater reduction in ADHD symptoms and better functional outcomes.

Conclusions

These findings parallel the adult AUD literature and provide preliminary support for the use 2-level reductions in WHO risk levels for alcohol use as a clinically valid non-abstinent treatment outcome for youth with ADHD and comorbid AUD.

A Cascade of Care for Alcohol Use Disorder: Using 2015-2018 National Survey on Drug Use and Health Data to Identify Gaps in Care

BACKGROUND

Although effective treatments exist, alcohol use disorder (AUD) is undertreated. We used a cascade of care framework to understand gaps in care between diagnosis and treatment for persons with AUD.

METHODS

Using 2015-2018 National Survey on Drug Use and Health data, we evaluated the following steps in the cascade of care: 1) prevalence of adults with AUD; 2) proportion of adults who utilized health care in the past 12 months; 3) were screened about alcohol use; 4) received a brief intervention about alcohol misuse; 5) received information about treatment for alcohol misuse; and 6) proportion of persons with AUD who received treatment. Analyses were stratified by AUD severity.

RESULTS

Of the 171,766 persons included in the sample, weighted prevalence of AUD was 7.9% (95% CI 7.7-8.0%). Persons with AUD utilized health care settings at similar rates as those without AUD. Cascades of care showed the majority of individuals with AUD utilized health care and were screened about alcohol use, but the percent who received the subsequent steps of care decreased substantially. For those with severe AUD, 83.5% (CI: 78.3%-88.7%) utilized health care in the past 12 months, 73.5% (CI: 68.1%-78.9%) were screened for alcohol use, 22.7% (CI: 19.4%-26.0%) received a brief intervention, 12.4% (CI: 10%-14.7%) received information about treatment, and 20.5% (CI: 18%-23.1%) were treated for AUD. The greatest decrease in the care continuum occurred from screening to brief intervention and referral to treatment. More persons with severe AUD received treatment than were referred, indicating other pathways to treatment outside of the healthcare system.

CONCLUSIONS

Persons with AUD utilize health care at high rates and are frequently screened about alcohol use, but few receive treatment. Health care settings-particularly primary care settings-represent a prime opportunity to implement pharmacologic treatment for AUD to improve outcomes in this high-risk population.

Frequent Alcohol Intoxication and High Alcohol Tolerance During Adolescence as Predictors of Mortality: A Birth Cohort Study

PURPOSE

Long-term prospective studies evaluating the health burden that is consequent to adolescent drinking are needed. The aim of this study was to examine the predictive associations between self-reported alcohol tolerance and frequent intoxication at age 15-16 years and the risk of death by age 33 years.

METHODS

A sample (n = 6,615; 49.3% males) of the Northern Finland Birth Cohort Study 1986 was studied. Self-reported alcohol tolerance (drinks needed to feel intoxicated) and frequency of alcohol intoxication at age 15-16 years were analyzed along with background variables and data regarding subsequent psychiatric diagnoses. Categories were formed for both predictive variables from self-reported tolerance and frequency of intoxication in mid-adolescence. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence interval (95% CI) for death by age 30 years.

RESULTS

By the age of 33 years, of all 6,615 participants, 53 (.8%) were deceased. The HR for death by age 33 years was 3.08 (95% CI 1.17-8.07) among adolescents with high alcohol tolerance compared with adolescents without alcohol use or intoxication. The frequency of alcohol intoxication was also associated with mortality; HR 2.05 (95% CI 1.01-4.16) for those who had been intoxicated one to two times and HR 3.02 (95% CI 1.21-7.54) for those who had been intoxicated three or more times in the past 30 days compared with adolescents without intoxication.

CONCLUSIONS

High self-reported alcohol tolerance and frequent alcohol intoxication during mid-adolescence significantly predicted death by age 33 years. These behaviors carry long-term repercussions with respect to premature loss of life. Substantial efforts should be made to diminish this mortality risk.

Prospects of Genetics and Epigenetics of Alcohol Use Disorder

Purpose of Review

In this study, we illustrate recent findings regarding the genetics and epigenetics of alcohol use disorder (AUD). We further outline the future direction of genetic and epigenetic research in AUD.

Recent Findings

Recent genome- and epigenome-wide studies allow new insight into genetic and epigenetic variation associated with AUD. The largest EWAS of AUD so far/to date found evidence for altered glucocorticoid receptor regulation. Longitudinal studies provide insight into the dynamics of the disease. Analyses of postmortem brain tissue reveal the impact of chronic alcohol consumption on DNA methylation in the brain.

Summary

Genetic and environmental factors—mediated via epigenetic mechanisms—play an important role in AUD. Although knowledge of the biological underpinnings of AUD is still limited, ongoing research will ultimately lead to the development of biomarkers for disease classification, course of disease, and treatment response to support personalized medicine in the future.

Comorbidity of substance misuse with anxiety-related and depressive disorders: a genetically informative population study of 3 million individuals in Sweden

BACKGROUND

Causes of the comorbidity of substance misuse with anxiety-related and depressive disorders (anxiety/depression) remain poorly known. We estimated associations of substance misuse and anxiety/depression in the general population and tested them while accounting for genetic and shared environmental factors.

METHODS

We studied individuals born in Sweden 1968-1997 (n = 2 996 398) with follow-up in nationwide register data for 1997-2013. To account for familial effects, stratified analyses were conducted within siblings and twin pairs. Substance misuse was defined as ICD-10 alcohol or drug use disorder or an alcohol/drug-related criminal conviction. Three dimensions of ICD-10 anxiety and depressive disorders and a substance misuse dimension were identified through exploratory factor analysis.

RESULTS

Substance misuse was associated with a 4.5-fold (95% CI 4.50-4.58) elevated risk of lifetime generalized anxiety/depression, 4.7-fold (95% CI 4.63-4.82) elevated risk of panic disorder and agora/social phobia, and 2.9-fold elevated risk of phobias/OCD (95% CI 2.82-3.02) as compared to those without substance misuse. The associations were attenuated in within-family analyses but we found elevated risks in monozygotic twin pairs discordant for substance misuse as well as significant non-shared environmental correlations. The association between anxiety/depression and substance misuse was mainly driven by generalized anxiety/depression, whereas other anxiety/depression dimensions had minor or no independent associations with substance misuse.

CONCLUSIONS

Substance misuse and anxiety/depression are associated at the population level, and these associations are partially explained by familial liabilities. Our findings indicate a common genetic etiology but are also compatible with a potential partially causal relationship between substance misuse and anxiety/depression.

Alcohol Use Disorder and Risk of Suicide in a Swedish Population-Based Cohort

OBJECTIVE

The authors examined the association between alcohol use disorder (AUD) and risk of suicide, before and after accounting for psychiatric comorbidity, and assessed the extent to which the observed association is due to a potentially causal mechanism or genetic and familial environmental confounding factors that increase risk for both.

METHODS

Longitudinal population-wide Swedish medical, criminal, and pharmacy registries were used to evaluate the risk of death by suicide as a function of AUD history. Analyses employed prospective cohort and co-relative designs, including data on 2,229,880 native Swedes born between 1950 and 1970 and observed from age 15 until 2012.

RESULTS

The lifetime rate of suicide during the observation period was 3.54% for women and 3.94% for men with AUD, compared with 0.29% and 0.76% of women and men, respectively, without AUD. In adjusted analyses, AUD remained robustly associated with suicide: hazard ratios across observation periods ranged from 2.61 to 128.0 among women and from 2.44 to 28.0 among men. Co-relative analyses indicated that familial confounding accounted for some, but not all, of the observed association. A substantial and potentially causal relationship remained after accounting for a history of other psychiatric diagnoses.

CONCLUSIONS

AUD is a potent risk factor for suicide, with a substantial association persisting after accounting for confounding factors. These findings underscore the impact of AUD on suicide risk, even in the context of other mental illness, and implicate the time frame shortly after a medical or criminal AUD registration as critical for efforts to reduce alcohol-related suicide.

Mortality of treatment-seeking men and women with alcohol, opioid or other substance use disorders - A register-based follow-up study

BACKGROUND

Alcohol (AUD), opioid (OUD) and other substance use disorders (SUD) are associated with an increased risk of premature death. The aim of this register-based follow-up study was to compare the risk of death between individuals who had sought treatment for AUDs, OUDs and other SUDs in Finland.

DESIGN, SETTING, PARTICIPANTS

Data included 10,888 individuals who had sought help from three clinics at some point between 1990 and 2009. Treatment data were linked to national register data concerning education, hospitalizations and death by the year 2018.

MEASUREMENTS

Individuals were categorized into four groups: only alcohol (AUD-only), all OUDs (OUD-all), other or multiple SUDs (SUD-other) and outpatients without substance-related diagnoses or hospitalizations (SU-NAS); in mortality analyses, those who had started in opioid substitution treatment (OST) were analyzed separately. COX regression analyses were used to calculate the risk of death by the year 2018 or up to 15 years after seeking treatment.

RESULTS

Among the 10,888 treatment-seeking individuals the cumulative mortality rates during 1-, 5- and 15-year follow-up were 2.5% (n = 271), 10.9% (n = 1191) and 28.4% (n = 3096), respectively. The mean age at death varied according to substance of use (55.0 years for AUD-only, 35.8 OUD-all, 45.8 SUD-other and 55.6 SU-NAS). The patients who had started in OST had a lower risk of death compared to the other groups, as did the SU-NAS group that likely included individuals with a less severe course of AUDs/SUDs. There were no differences between the AUD-only, OUD-other and SUD-other groups for the risk of death during the 15-year follow-up period when gender and year of birth were included as covariates.

CONCLUSIONS

The mortality rates were very high; however, most of the deaths occurred several years after seeking treatment. The lower mortality amongst the patients who had initiated OST solidifies previous knowledge on the benefits of OST and efforts should be made to improve access to treatment. These results show that treatment plays a role in lowering the risk of death among individuals with AUDs/SUDs.

Alcohol and Human Health: What Is the Evidence?

Alcohol consumption has long been a part of human culture. However, alcohol consumption levels and alcohol consumption patterns are associated with chronic diseases. Overall, light and moderate alcohol consumption (up to 14 g per day for women and up to 28 g per day for men) may be associated with reduced mortality risk, mainly due to reduced risks for cardiovascular disease and type-2 diabetes. However, chronic heavy alcohol consumption and alcohol abuse lead to alcohol-use disorder, which results in physical and mental diseases such as liver disease, pancreatitis, dementia, and various types of cancer. Risk factors for alcohol-use disorder are largely unknown. Alcohol-use disorder and frequent heavy drinking have detrimental effects on personal health.

High-risk social drinkers and heavy drinkers display similar rates of alcohol consumption

Alcohol consumption is often assessed over weeks to months, but few attempts have been made to characterize alcohol consumption rates at the level of an individual drinking session. Here, we aimed to compare the rate of alcohol consumption in social drinkers at high risk for alcohol use disorder (AUD) and heavy drinkers. One hundred and sixty social drinkers and 48 heavy drinkers participated in an alcohol self-administration study. Social drinkers were classified as low risk or high risk for AUD based on sex, impulsivity, and family history of alcoholism. Participants received a priming dose of intravenous alcohol to assess alcohol-induced craving and completed a 125-minute intravenous alcohol self-administration session to assess rate of achieving a binge-level exposure (blood alcohol concentration greater than or equal to 80 mg%). There were no differences between rates of binging in high-risk and heavy drinkers (hazard ratio = 0.87; 95% CI, 0.48-1.56). Heavy drinkers reported higher levels of craving than high-risk and low-risk drinkers at baseline. However, following a priming dose of alcohol, there were no longer differences in craving between high-risk and heavy drinkers. These results indicate that high-risk social drinkers demonstrate binging behavior that is similar to heavy drinkers, which may be driven by alcohol-induced craving. Prospective studies are needed to elucidate whether these patterns of craving and consumption in high-risk social drinkers are predictive of future AUD.

Alcohol use and its consequences in the Czech Republic

OBJECTIVE

Alcohol consumption is associated with substantial public health burden. This article summarises available information on the patterns and prevalence of alcohol use in the Czech Republic with a focus on the heavy alcohol use and its health and social consequences.

METHODS

A non-systematic literature review was conducted. The data sources included primarily 3 series of surveys in the adult population, 2 series of surveys in the school population, routine monitoring system of per capita alcohol consumption, routine statistics on alcohol-related morbidity and mortality, and alcohol-related crime.

RESULTS

In recent years the registered alcohol consumption in the Czech Republic has been very high; 9.8 litres of pure alcohol were consumed per capita in 2017. Recently, the prevalence of hazardous alcohol consumption in the adult population has reached 16.8-17.6% and harmful alcohol consumption 9.0-9.3%. From 12% to 17% of adult population and 12% of adolescent population were heavy episodic drinkers. Alcohol-related disorders are disproportionately higher (2-3 times) among men. Mortality for alcohol-related causes fully attributable to alcohol (AAF = 100%) and their proportion in overall mortality is on increase.

CONCLUSIONS

Alcohol consumption as well as the prevalence of heavy episodic drinking in the Czech Republic belongs among the highest globally. On the other hand, declines in alcohol use have been recently observed among children and adolescents. Available data on alcohol-related morbidity indicate stable situation, though alcohol-related mortality is increasing. Alcohol-related burden is rather underestimated and evidence-based alcohol policy should be increasingly implemented.

Epigenetic aging is accelerated in alcohol use disorder and regulated by genetic variation in APOL2

To investigate the potential role of alcohol use disorder (AUD) in aging processes, we employed Levine's epigenetic clock (DNAm PhenoAge) to estimate DNA methylation age in 331 individuals with AUD and 201 healthy controls (HC). We evaluated the effects of heavy, chronic alcohol consumption on epigenetic age acceleration (EAA) using clinical biomarkers, including liver function test enzymes (LFTs) and clinical measures. To characterize potential underlying genetic variation contributing to EAA in AUD, we performed genome-wide association studies (GWAS) on EAA, including pathway analyses. We followed up on relevant top findings with in silico expression quantitative trait loci (eQTL) analyses for biological function using the BRAINEAC database. There was a 2.22-year age acceleration in AUD compared to controls after adjusting for gender and blood cell composition (p = 1.85 × 10^-5). This association remained significant after adjusting for race, body mass index, and smoking status (1.38 years, p = 0.02). Secondary analyses showed more pronounced EAA in individuals with more severe AUD-associated phenotypes, including elevated gamma-glutamyl transferase (GGT) and alanine aminotransferase (ALT), and higher number of heavy drinking days (all ps < 0.05). The genome-wide meta-analysis of EAA in AUD revealed a significant single nucleotide polymorphism (SNP), rs916264 (p = 5.43 × 10^-8), in apolipoprotein L2 (APOL2) at the genome-wide level. The minor allele A of rs916264 was associated with EAA and with increased mRNA expression in hippocampus (p = 0.0015). Our data demonstrate EAA in AUD and suggest that disease severity further accelerates epigenetic aging. EAA was associated with genetic variation in APOL2, suggesting potential novel biological mechanisms for age acceleration in AUD.

Effect of a Snack Bar Optimized to Reduce Alcohol Bioavailability: A Randomized Controlled Clinical Trial in Healthy Individuals

Alcohol intoxication impairs judgment and reaction times and the level of blood alcohol concentration (BAC) is highly correlated with accidents and injury. We hypothesized that a food optimized to delay gastric emptying, a reduced alcohol bioavailability bar (RABB), would decrease postprandial BAC and alcohol bioavailability with greater caloric-efficiency than control foods. Therefore, we evaluated the RABB in a randomized, crossover trial in 21 overnight fasted healthy adults (10 male, 11 female). Just before consuming a moderate dose of alcohol (0.3-0.35 g/kg body weight), participants ate either (1) no food (NF, 0 kcal), (2) the RABB (210 kcal), (3) a savory snack mix (SSM, 210 kcal), or (4) a multicomponent meal (MCM, 635 kcal) and their BAC was measured over 90 minutes using a breathalyzer, the primary endpoint being peak BAC (pBAC). pBACs were analyzed by repeated measures analysis of variance (ANOVA) (F = 107.5, P < .0001) with the differences between means assessed using Tukey's honestly significant difference test. The pBAC of each group was different (P < .001) from all other groups (NF = 0.064 ± 0.003, SSM = 0.047 ± 0.002, RABB = 0.031 ± 0.002, MCM = 0.020 ± 0.002%; mean ± standard error of the mean). Furthermore, the bioavailability of alcohol over 90 minutes (BA90) was reduced compared to the NF group by similar margins (SSM = 22.0 ± 2.2, RABB = 45.0 ± 3.8, MCM = 67.9 ± 3.1%) with the mean BA90 of each group different from all other groups (P < .001). Compared to the NF condition, the average reduction of pBAC per 100 calories of food consumed was higher for the RABB (24.0%) than either the SSM (11.8%) or the MCM (10.7%). This study demonstrates that the RABB can reduce both pBAC and alcohol bioavailability with high caloric-efficiency.

Predictors of initiation of and retention on medications for alcohol use disorder among people living with and without HIV

INTRODUCTION

Infrequent use of and poor retention on evidence-based medications for alcohol use disorder (MAUD) represent a treatment gap, particularly among people living with HIV (PLWH). We examined predictors of MAUD initiation and retention across HIV status.

METHODS

From Veterans Aging Cohort Study (VACS) data, we identified new alcohol use disorder (AUD) diagnoses from 1998 to 2015 among 163,339 individuals (50,826 PLWH and 112,573 uninfected, matched by age, sex, and facility). MAUD initiation was defined as a prescription fill for naltrexone, acamprosate or disulfiram within 30 days of a new diagnosis. Among those who initiated, retention was defined as filling medication for ≥80% of days over the following six months. We used multivariable logistic regression to assess patient- and facility-level predictors of AUD medication initiation across HIV status.

RESULTS

Among 10,603 PLWH and 24,424 uninfected individuals with at least one AUD episode, 359 (1.0%) initiated MAUD and 49 (0.14%) were retained. The prevalence of initiation was lower among PLWH than those without HIV (adjusted odds ratio [AOR] 0.66, 95% confidence interval [CI] 0.51-0.85). Older age (for PLWH: AOR 0.78, 95% CI 0.61-0.99; for uninfected: AOR 0.70, 95% CI 0.61-0.80) and black race (for PLWH: AOR 0.63, 95% CI 0.0.49-0.1.00; for uninfected: AOR 0.63, 95% CI 0.48-0.83), were associated with decreased odds of initiation for both groups. The low frequency of retention precluded multivariable analyses for retention.

CONCLUSIONS

For PLWH and uninfected individuals, targeted implementation strategies to expand MAUD are needed, particularly for specific subpopulations (e.g. black PLWH).

Drug-related mortality after discharge from treatment: A record-linkage study of substance abuse clients in Texas, 2006-2012

BACKGROUND

Patients have higher mortality immediately after substance abuse treatment discharge, but there are few data on post-discharge mortality differences across treatment modalities.

METHODS

A retrospective cohort study examined individuals discharged from substance abuse treatment during 2006-2012 and probabilistically matched treatment records to death records. Logistic regression examined associations between drug-related death (DRD) and demographics; route, frequency, and classes of drugs abused; and treatment. Primary outcome was DRD during post-discharge days 0-28; secondary outcomes examined DRD during days 29-90 and 91-365.

RESULTS

We examined 178,749 patients discharged from 254,814 treatment episodes. There were 97 DRD during days 0-28 (4.1/1000 person-years), 115 DRD during days 29-90 (2.6/1000 person-years; IRR 0.6 [95% CI 0.5-0.8]), and 293 DRD during days 91-365 (1.9/1000 person-years; IRR 0.5 [0.4-0.6]). Higher 28-day DRD was associated with abuse of opioids (aOR 2.5 [1.4-4.4]), depressants (aOR 2.0 [1.2-3.4]), or alcohol (aOR 1.7 [1.1-2.6]); and opioid injection (aOR 2.2 [1.3-3.7]). Lower DRD was associated with treatment completion (aOR 0.6 [0.4-0.9]), female sex (aOR 0.6 [0.4-0.8]), and employment (aOR 0.5 [0.3-0.9]). Among all patients, DRD rates were higher following residential (IRR 2.6, [1.6-4.2]) and detoxification (IRR 2.9, [1.7-4.9]) treatment compared to outpatient. Patients with prior opioid abuse had higher 28-day DRD after outpatient (6.7/1000 person-years; IRR 4.1 [1.8-9.1]), residential (13.6/1000 person-years; IRR 4.2 [2.2-8.2]), and detoxification (8.8/1000 person-years; IRR 3.2 [1.2, 8.5]) compared to those without.

CONCLUSIONS

Drug-related mortality is highest during days 0-28 after discharge, especially following residential and detoxification treatment. Opioid abuse is strongly associated with early post-discharge mortality.

Estimating Long-Term Drinking Patterns for People with Lifetime Alcohol Use Disorder

Background. There is a lack of data on alcohol consumption over time. This study characterizes the long-term drinking patterns of people with lifetime alcohol use disorders who have engaged in treatment or informal care. Methods. We developed multinomial logit models using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to estimate short-term transition probabilities (TPs) among the 4 World Health Organization drinking risk levels (low, medium, high, and very high risk) and abstinence by age, sex, and race/ethnicity. We applied an optimization algorithm to convert 3-year TPs from NESARC to 1-year TPs, then used simulated annealing to calibrate TPs to a propensity-scored matched set of participants derived from a separate 16-year study of alcohol consumption. We validated the resulting long-term TPs using NESARC-III, a cross-sectional study conducted on a different cohort. Results. Across 24 demographic groups, the 1-year probability of remaining in the same state averaged 0.93, 0.81, 0.49, 0.51, and 0.63 for abstinent, low, medium, high, and very high-risk states, respectively. After calibration to the 16-year study data (N = 420), resulting TPs produced state distributions that hit the calibration target. We find that the abstinent or low-risk states are very stable, and the annual probability of leaving the very high-risk state increases by about 20 percentage points beyond 8 years. Limitations. TPs for some demographic groups had small cell sizes. The data used to calibrate long-term TPs are based on a geographically narrow study. Conclusions. This study is the first to characterize long-term drinking patterns by combining short-term representative data with long-term data on drinking behaviors. Current research is using these patterns to estimate the long-term cost effectiveness of alcohol treatment.

Belief, Behavior, and Belonging: How Faith is Indispensable in Preventing and Recovering from Substance Abuse

This study reviews the voluminous empirical evidence on faith's contribution to preventing people from falling victim to substance abuse and helping them recover from it. We find that 73% of addiction treatment programs in the USA include a spirituality-based element, as embodied in the 12-step programs and fellowships initially popularized by Alcoholics Anonymous, the vast majority of which emphasize reliance on God or a Higher Power to stay sober. We introduce and flesh out a typology of faith-based substance abuse treatment facilities, recovery programs, and support groups. This typology provides important background as we then move on to make an economic valuation of nearly 130,000 congregation-based substance abuse recovery support programs in the USA. We find that these faith-based volunteer support groups contribute up to $316.6 billion in savings to the US economy every year at no cost to tax payers. While negative experiences with religion (e.g., clergy sex abuse and other horrendous examples) have been a contributory factor to substance abuse among some victims, given that more than 84% of scientific studies show that faith is a positive factor in addiction prevention or recovery and a risk in less than 2% of the studies reviewed, we conclude that the value of faith-oriented approaches to substance abuse prevention and recovery is indisputable. And, by extension, we also conclude that the decline in religious affiliation in the USA is not only a concern for religious organizations but constitutes a national health concern.

Childhood adversities and 5-HTTLPR polymorphism as risk factors of substance use disorders: retrospective case-control study in Murcia (Spain)

OBJECTIVE

To explore the separate and joint associations of childhood adversities and 5-HTTLPR polymorphism as risk factors for substance use disorders among adults. : Design : Retrospective case-control study.

SETTING

Cases from the substance unit and controls from a representative sample of the adult general population in the metropolitan area of Murcia (Spain).

PARTICIPANTS

Cases were defined as outpatients 18 years old or older currently in the treatment for alcohol, opioids or cocaine use disorders in the clinical unit. Controls were randomly selected among individuals without substance use disorders who participated in the Psychiatric Enquiry to General Population in Southeast Spain-Murcia (PEGASUS-Murcia) project, a cross-sectional study of a representative sample of the adult general population. In all, 142 cases and 531 controls were interviewed and a subsample of 114 cases (80.3%) and 329 controls (62%) provided a biological sample.

EXPOSURE

A history of 12 childhood adversities, lifetime mental disorders and sociodemographic variables was assessed with the Composite International Diagnostic Interview (CIDI)version 3.0). Buccal swabs were obtained to genotype the 5-HTTLPR polymorphism with the biallelic and the triallelic classification.

MAIN OUTCOME AND MEASURE

Multivariable logistic regression models were performed to estimate adjusted ORs and 95% CI.

RESULTS

Childhood adversities were associated with an elevated risk of substance use disorders (OR=5.77, 95% CI 3.46 to 9.61). Homozygotes for the short allele of the 5-HTTLPR polymorphism also showed the elevated risk of substance use disorders for the biallelic and triallelic classification: (1.97 (1.10 to 3.55) and 2.01 (1.11 to 3.64), respectively). No evidence for gene × environment interactions was found.

CONCLUSIONS

Childhood adversities and the 5-HTTLPR polymorphism are involved in the aetiology of substance use disorders though findings exploring the existence of a gene-environment interaction were inconclusive.

Using Machine Learning to Classify Individuals With Alcohol Use Disorder Based on Treatment Seeking Status

OBJECTIVE

The authors used a decision tree classifier to reduce neuropsychological, behavioral and laboratory measures to a subset of measures that best predicted whether an individual with alcohol use disorder (AUD) seeks treatment.

METHOD

Clinical measures (N = 178) from 778 individuals with AUD were used to construct an alternating decision tree (ADT) with 10 measures that best classified individuals as treatment or not treatment-seeking for AUD. ADT's were validated by two methods: using cross-validation and an independent dataset (N = 236). For comparison, two other machine learning techniques were used as well as two linear models.

RESULTS

The 10 measures in the ADT classifier were drinking behavior, depression and drinking-related psychological problems, as well as substance dependence. With cross-validation, the ADT classified 86% of individuals correctly. The ADT classified 78% of the independent dataset correctly. Only the simple logistic model was similar in accuracy; however, this model needed more than twice as many measures as ADT to classify at comparable accuracy.

INTERPRETATION

While there has been emphasis on understanding differences between those with AUD and controls, it is also important to understand, within those with AUD, the features associated with clinically important outcomes. Since the majority of individuals with AUD do not receive treatment, it is important to understand the clinical features associated with treatment utilization; the ADT reported here correctly classified the majority of individuals with AUD with 10 clinically relevant measures, misclassifying < 7% of treatment seekers, while misclassifying 38% of non-treatment seekers. These individual clinically relevant measures can serve, potentially, as separate targets for treatment.

FUNDING

Funding for this work was provided by the Intramural Research Programs of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA) and the Center for Information Technology (CIT).

RESEARCH IN CONTEXT

Evidence Before This Study: Less than 10% of persons who meet lifetime criteria for Alcohol Use Disorder (AUD) receive treatment. As the etiology of AUD represents a complex interaction between neurobiological, social, environmental and psychological factors, low treatment utilization likely stems from barriers on multiple levels. Given this issue, it is important from both a research and clinical standpoint to determine what characteristics are associated with treatment utilization in addition to merely asking individuals if they wish to enter treatment. At the level of clinical research, if there are phenotypic differences between treatment and nontreatment-seekers that directly influence outcomes of early-phase studies, these phenotypic differences are a potential confound in assessing the utility of an experimental treatment for AUD. At the level of clinical practice, distinguishing between treatment- and nontreatment-seekers may help facilitate a targeted treatment approach. Previous efforts to understand the differences between these populations of individuals with AUD leveraged the multidimensional data collected in clinical research settings for AUD that are not well suited to traditional regression methods.Added Value of This Study: Alternating decision trees are well suited to deep-phenotyping data collected in clinical research settings as this approach handles nonparametric, skewed, and missing data whose relationships are nonlinear. This approach has proved to be superior in some cases to conventional clinical methods to solve diagnostic problems in medicine. We used a decision tree classifier to understand treatment- and non-treatment seeking group differences. The decision tree classifier approach chose a subset of factors arranged in an alternating decision tree that best predicts a given outcome. Assuming that the input measures are clinically relevant, the alternating decision tree that is generated has clinical value. Unlike other machine learning approaches, in addition to its predictive value, the nodes in the tree and their arrangement in a hierarchy have clinical utility. With the "if-then" logic of the tree, the clinician can learn what features become important and which recede in importance as the logic of the tree is followed. The decision tree classifier approach reduced 178 characterization measures (both categorical and continuous) in multiple domains to a decision tree comprised of 10 measures that together best classified subjects by treatment seeking status (yes/no).Implications After All the Available Evidence: We leveraged a large data set comprised of 178 clinical measures and using the decision tree approach, we have reduced these to a subset of 10 measures that accurately classified individuals with alcohol dependence by treatment utilization. From this analysis, drinking behavior variables and depression measures are strong treatment seeking predictors. Having identified a cluster of factors that predicts treatment seeking, we can assess the influence of these factors directly on the clinical study outcome measures themselves. In clinical practice these factors can be separate targets for treatment. In clinical research, the group differences my directly influence research outcomes for treatment of AUD.

Prevalence, treatment, and the correlates of common mental disorders in the mid 2010's in Japan: The results of the world mental health Japan 2nd survey

BACKGROUND

Despite numerous changes in the mental health care system in Japan in 2000's, little is known about changes in the prevalence or treatment rates of mental disorders.

METHODS

The World Mental Health Japan (WMHJ) 2nd Survey was a nationally representative face-to-face household survey of residents aged 20-75 years old conducted between 2013 and 2015. We compared the findings with those of an earlier study, the first WMHJ (WMHJ1) survey, conducted in 2002-2006.

RESULTS

Overall, 2450 residents completed the interview. Lifetime prevalence of any common mental disorder was 22%, with high prevalence of alcohol abuse (15.1%). Twelve-month prevalence rates of any common mental disorder and major depressive disorder were 5.2% and 2.7%, respectively. Severe cases comprised 24% of 12-month disorders. Lifetime prevalence of any common mental disorder was greater for males. The persistence of any common mental disorder was greater for females. Proportion of those with 12-month disorders who sought treatment was 34%. Mental health care use was the most prevalent among 12-month cases. Twelve-month prevalence of any common mental disorder was similar to that of the WMHJ1 while the proportion of seeking treatment increased for disorders with moderate severity.

LIMITATIONS

Institutionalized people were not included. The lower response rate might also limit the interpretation of the findings.

CONCLUSIONS

The study found lower prevalence of mental disorders in Japan than in Western countries in the mid 2010's, suggesting that the prevalence of mental disorders remained stable in the last decade in Japan. Treatment rate increased for those with moderate disorders, which might reflect the government's attempt to raise people's awareness of mental health.

Gambling disorder, increased mortality, suicidality, and associated comorbidity: A longitudinal nationwide register study

BACKGROUND AND AIMS

Gambling disorder (GD) appears to be an independent risk factor for suicide, and all-cause mortality has been sparsely studied in patients with GD. This study aims to explore mortality and suicide rates in individuals with GD compared to the general population as well as explore risk factors associated with all-cause mortality and suicide mortality.

METHODS

This is a nationwide register study on 2,099 individuals with a GD diagnosis in the Swedish inpatient and/or outpatient specialist health care system between the years of 2005-2016. Comorbid diagnoses from treatment episodes included in national registers were categorized into diagnostic groups according to the 10th revision of International Classification of Diseases, and prevalence rates (any occurrence during 2005-2016) were calculated for each diagnostic group. Multivariate Cox regression analyses on risk factors for death and suicide were performed, controlling for age, gender, and major categories of comorbidity. Standardized mortality ratios (SMRs) were calculated for men and women with regard to overall mortality and suicide compared to the general Swedish population.

RESULTS

The population consisted of 1,625 men and 474 women ranging from 18 to 83 years of age at first GD diagnosis (mean: 36.5 years). Sixty-seven individuals passed away, among whom 21 deaths were due to suicide. SMR calculations showed a 1.8-fold increase in mortality for individuals 20-74 years old with GD compared to the general population, and a 15-fold increase in suicide mortality. All-cause mortality was predicted by higher age and any treatment episode for cardiovascular disease, whereas suicide death was predicted by depression.

DISCUSSION AND CONCLUSIONS

Mortality and suicide rates are significantly elevated among individuals with GD. Although common mental health comorbidities did not predict overall mortality, depression predicted suicide death. Findings call for attention to long-term risk of death in GD patients and interventions against comorbid health problems.