Alcohol abuse and mortality: a 40-year prospective study of Norwegian conscripts

Incidence of and risk factors for alcohol dependence in bipolar disorder: A population-based cohort and nested case-control study

OBJECTIVES

Although alcohol dependence is highly prevalent in patients with bipolar disorder, the causal relationship is not yet well-established. This study estimated the incidence of alcohol dependence in a nationwide bipolar disorder cohort and examined risk factors for alcohol dependence.

METHODS

Patients aged 15-65 years with consistent bipolar disorder who had their first psychiatric admission between 1999 and 2012 (n = 21,791) were enrolled from the National Health Insurance Research Database in Taiwan. We calculated the adjusted incidence rate ratio of alcohol dependence in the bipolar cohort relative to the general population after stratification by age and sex. In the nested case-control study, we included patients with incident alcohol dependence as cases and four age- and sex-matched controls for each case to analyze health care utilization, comorbidities and concomitant medications between them.

RESULTS

We identified 1261 patients with bipolar disorder with incident alcohol dependence. Relative to the general population, the adjusted incidence rate ratio of alcohol dependence was 9.20 in the bipolar cohort. All adjusted incidence rate ratios were high across all age subgroups. Cases had higher psychiatric and nonpsychiatric health care utilization than did controls. Multivariate analysis revealed that cases tended to have cardiovascular disease, diabetes mellitus, chronic hepatic disease, pneumonia and delirium before alcohol dependence diagnosis. Cases had higher psychiatric comorbidities, namely drug-induced mental disorders, anxiety disorder, personality disorder, adjustment disorder and sleep disorder.

CONCLUSION

The bipolar cohort had a higher incidence of alcohol dependence. We identified specific groups with a high risk of alcohol dependence. Additional strategies for early detection, treatment and intervention for alcohol dependence should be developed.

Identification and medical utilization of incident cases of alcohol dependence: A population-based case-control study

BACKGROUND

Patients with alcohol dependence (AD) often seek help from medical professionals due to alcohol-related diseases, but the overall distribution of medical specialties identifying new AD cases is unclear. We investigated how such cases were identified and how medical resources were utilized before the identification of AD in a nationwide cohort.

METHODS

We enrolled a population-based cohort (N = 1,000,000) using the National Health Insurance Research Database of Taiwan; 8181 cases with incident AD were retrieved between January 1, 2000, and December 31, 2010. For this nested case-control study, four controls were matched for age and sex with each case based on risk-set sampling. We measured various dimensions of medical utilization before AD was diagnosed, including department visited, physical comorbidity, and medication used. Conditional logistic regression was used for estimating the variables associated with AD.

RESULTS

Patients living in less urbanized areas who were unemployed were more likely to develop AD. The highest proportions (34.2%) of AD cases were identified in the internal medicine department, followed by the emergency (22.3%) and psychiatry (18.7%) departments. AD patients had a higher risk of comorbid chronic hepatic disease (adjusted RR = 2.72, p < 0.001) before identification of AD than controls. AD patients also had greater numbers of hospital admissions than controls, including non-psychiatric and psychiatric hospitalizations. Outpatient visit numbers were similar for AD patients and controls.

CONCLUSIONS

The findings indicate that clinicians providing care in diverse medical settings should be prepared to screen for unhealthy alcohol use and to mitigate its detrimental effects.

Anger Experience and Anger Inhibition in Sub-Populations of African American and European American Older Adults and Relation to Circulatory Disease

This study examined ethnic differences in the link between anger experience and anger inhibition and that of circulatory disease (CD). To ascertain the effects of anger inhibition in older persons, health data from groups of African American, African Caribbean, Eastern European and European American adults were collected. Experienced anger and anger inhibition were significant predictors of CD only for the African American group and the relation between experienced anger and CD was mediated by anger inhibition. The data suggest that cultural factors play a role in the development of an angerinhibitory style and that this trait may pose a serious risk factor for circulatory disease.

Reduzierung alkoholbedingter Mortalität durch Behandlung der Alkoholabhängigkeit

Fragestellung: Ziel dieser Studie ist es, die von riskantem Trinken und von Alkoholabhängigkeit in Deutschland verursachte Krankheitslast zu quantifizieren. Weiterhin sollen die erwartbaren Auswirkungen eines verbesserten Zugangs von Alkoholabhängigen zu effektiven Therapien auf die alkoholbedingte Sterblichkeit abgeschätzt werden. Methodik: Die Krankheitslast wurde anhand von „Attributable Fractions“ berechnet, die den durch die jeweilige Exposition bedingten Anteil an den Todesfällen einer umfassenden Liste von durch Alkohol verursachten Krankheiten beziffern. Mögliche Auswirkungen eines verbesserten Zugangs zu Behandlungen wurden berechnet durch modellgemäße Veränderungen in der Zusammensetzung der trinkenden Bevölkerung. Alle Modelle legten das Jahr 2004 und die Bevölkerung zwischen 15 und 64 Jahren zugrunde, d. h. ausschließlich vorzeitige Todesfälle wurden berücksichtigt. Ergebnisse: Riskantes Trinken ist bei Frauen für rund 58 % und bei Männern für rund 71 % aller vorzeitigen alkoholbedingten Todesfälle ursächlich. Die entsprechenden Anteile der mit riskantem Trinken stark überlappenden Kategorie der Alkoholabhängigkeit liegen bei 40 % (Frauen) und 68 % (Männer). Eine Erhöhung der gegenwärtigen Behandlungsquote auf 40 % aller Alkoholabhängigen zeitigte eine Verringerung um bis zu 13,1 % bei den männlichen und 10,7 % bei den weiblichen alkoholbedingten Todesfällen innerhalb eines Jahres, eine Erhöhung auf 20 % war mit einer Verringerung um bis zu 6.5 % bei den männlichen und 5.3 % bei den weiblichen alkoholbedingten Todesfällen verbunden. Schlussfolgerungen: Durch einen verbesserten Zugang besonders der abhängig Erkrankten zu effektiven therapeutischen Interventionen könnte ein bedeutsamer Teil der alkoholbedingten Krankheitslast vermindert werden.

Alcohol use disorders and mortality: a systematic review and meta-analysis

AIMS

To conduct a systematic review and meta-analysis on all-cause mortality in people with alcohol use disorders.

METHODS

Using the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines, studies were identified through MEDLINE, EMBASE, and Web of Science up to August, 2012. Prospective and historical cohort studies including a comparison of alcohol use disorder with a control group investigating all-cause mortality risk were included.

RESULTS

This meta-analysis included 81 observational studies with 221 683 observed deaths among 853 722 people with alcohol use disorder. In men, the relative risk (RR) among clinical samples was 3.38 (95% confidence interval [CI]: 2.98-3.84); in women it was 4.57 (95% CI: 3.86-5.42). Alcohol use disorders identified in general population surveys showed a twofold higher risk compared with no alcohol use disorder in men; no data were available for women. RRs were markedly higher for those ≤40 years old (ninefold in men, 13-fold in women) while still being at least twofold among those aged 60 years or older.

CONCLUSIONS

Mortality in people with alcohol use disorders is markedly higher than thought previously. Women have generally higher mortality risks than men. Among all people with alcohol use disorders, people in younger age groups and people in treatment show substantially higher mortality risk than others in that group.

Taxometric analysis of DSM-IV and DSM-5 alcohol use disorders

BACKGROUND

With preparations currently being made for the Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5), one prominent issue to resolve is whether alcohol use disorders are better represented as discrete categorical entities or as a dimensional construct. The purpose of this study was to investigate the latent structure of DSM-4th edition (DSM-IV) and proposed DSM-5 alcohol use disorders.

METHODS

The study used the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to conduct taxometric analyses of DSM-IV and DSM-5 alcohol use disorders defined by different thresholds to determine the taxonic or dimensional structure underlying the disorders.

RESULTS

DSM-IV and DSM-5 alcohol abuse and dependence criteria with 3+ thresholds demonstrated a dimensional structure. Corresponding thresholds with 4+ criteria were clearly taxonic, as were thresholds defined by cut-offs of 5+ and 6+ criteria.

CONCLUSIONS

DSM-IV and DSM-5 alcohol use disorders demonstrated a hybrid taxonic-dimensional structure. That is, DSM-IV and DSM-5 alcohol use disorders may be taxonically distinct compared to no disorder if defined by a threshold of 4 or more criteria. However, there may be dimensional variation remaining among non-problematic to subclinical cases. A careful and systematic program of structural research using taxometric and psychometric procedures is warranted.

Determinants of 40-year all-cause mortality in the European cohorts of the Seven Countries Study

If a few risk factors had predictive power for all-cause mortality in different geographical-cultural areas, then preventive efforts might be concentrated on these. Thirteen potential risk factors were measured in 6,554 men aged 40-59 around 1960 in Northern, Southern and Eastern European areas of the Seven Countries Study. In 40 years 85.3% of men died in the pooled areas (87.9, 81.8 and 87.9% in Northern, Southern and Eastern Europe, respectively). Six risk factors were significant predictors of events in all three areas: directly for age, smoking habits, mean blood pressure, heart rate and ECG abnormalities; inversely for forced expiratory volume. In a pooled model also father and mother life status, socio-economic status, and arm circumference (the last one in an inverse way) had significant coefficients that were not heterogeneous across areas (except for socio-economic status). Serum cholesterol was around significance. ROC curves had values of 0.833, 0.806 and 0.819 respectively in Northern, Southern and Eastern Europe, and 0.827 in the pooled areas. Correlation coefficients between observed and expected cases in deciles of estimated risk were between 0.98 and 0.99. Survivors after 40 years in the lower half of the estimated risk were 10.7, 23.6 and 13.3% in Northern, Southern and Eastern Europe, respectively. Under- or over-estimate of cross-applying risk functions did not exceed 15%. All-cause mortality and survival in middle aged men during 40 years were strongly associated with a few, mainly cardiovascular, risk factors, whose predictive power was similar in different cultures across Europe.

Severity of alcohol-related problems and mortality: results from a 20-year prospective epidemiological community study

There is evidence that high alcohol use is associated with an increase in mortality. Little is known about long-term effects of problematic alcohol consumption in non-clinical (community) populations. The aim of our study was to obtain data on this and related issues in a representative rural community sample assessed longitudinally over a period of 20 years. Assessments focused on a baseline survey from 1980 to 1984 and 20-year follow-up from 2001 to 2004. Based on expert interviews and standardized self-rating scales (e.g. MALT; Munich Alcoholism Test), the following three groups were defined (a) severe alcohol problems, (b) moderate alcohol problems, and (c) no alcohol problems. Mortality and hazard rates were analyzed with logistic and Cox regression adjusted for several health risk factors. From an original community sample of 1,465 individuals, 448 were deceased at 20-year follow-up. Participation rates were high. Baseline prevalence according to the MALT was 1.6% for severe alcohol problems and 4.0% for moderate alcohol problems. Over the 20-year time span, individuals with severe alcohol problems had a significantly elevated risk for dying earlier than the group with no alcohol problems (2.4 times higher). Mortality for those with moderate alcohol problems at baseline had a non-significantly elevated 20-year mortality risk (1.5 times higher) compared to those with no alcohol problems. Cox survival analyses corroborate these findings from multiple sequential logistic regression analyses. In discussing the mortality risk of persons with alcohol problems, the severity of the alcohol problems must be taken into account.

The burden of mental disorders

In the last decade, there has been an increase in interest in the burden of chronic and disabling health conditions that are not necessarily fatal, such as the mental disorders. This review systematically summarizes data on the burden associated with 11 major mental disorders of adults. The measures of burden include estimates of prevalence, mortality associated with the disorders, disabilities and impairments related to the disorders, and costs. This review expands the range of mental disorders considered in a report on the global burden of disease, updates the literature, presents information on the range and depth of sources of information on burden, and adds estimates of costs. The purpose is to provide an accessible guide to the burden of mental disorders, especially for researchers and policy makers who may not be familiar with this subfield of epidemiology.

Alcohol dependence, mortality, and chronic health conditions in a rural population in Korea

To determine the effects of excessive drinking and alcohol dependency on mortality and chronic health problems in a rural community in South Korea, this study represents a nested case-control study. In 1998, we conducted the Alcohol Dependence Survey (ADS), a population survey of a village in Korea. To measure the effects of alcohol on chronic health conditions and mortality over time, in 2004, we identified 290 adults from the ADS sample (N=1,058) for follow-up. Of those selected, 145 were adults who had alcohol problems, either alcohol dependence as assessed in the ADS by the Severity of Alcohol Dependence Questionnaire (N=59), or excessive drinking without dependency (N=86). Further 145 nondrinkers were identified, matching those with alcohol problems in age and sex. We revisited the village in 2004 and completed personal interviews with them. In multivariate logistic regressions, the rates of mortality and morbidity of chronic health conditions were three times greater for alcohol dependents compared with the rate for nondrinkers. Importantly, however, excessive drinking without dependency was not associated with the rates of either mortality or morbidity. Future investigations would benefit by attending more specifically to measures for alcohol dependence as well as measures for alcohol consumption.

Gender differences in role of alcohol in fatal injury events

BACKGROUND

The aim was to investigate the differences in alcohol involvement in fatal injury events between females and males.

METHODS

Information was obtained from the Forensic Medicine Database and the Forensic Toxicology Database of the National Board of Forensic Medicine, and from the inpatient register of the National Board of Health and Welfare. Alcohol was regarded to be involved in the injury event: if there was any indication that the deceased was a 'known alcoholic'; if the underlying or contributing causes of death were alcohol-related; if the deceased had alcohol-related inpatient diagnosis during a 3-year period prior to death; or if the deceased tested positive for blood alcohol at autopsy. All injured cases who underwent medico-legal autopsies (1992-1996) in Sweden were analysed (4471 females and 11 156 males).

RESULTS

Compared to males, females died more often (P < 0.05) in intentional injury events (48.0% females, 44.2% males), were less often (P < 0.001) blood alcohol-positive (29% females, 43% males), had lower (P < 0.05) blood alcohol concentrations (0.17% in females, 0.18% in males), and were less likely (P < 0.001) to have an alcohol-related history (18.4% females, 24.4% males). For females, intentional deaths (31.4%) were significantly (P < 0.001) more often alcohol-related than unintentional deaths (22.9%). A significantly (P < 0.001) higher proportion of deaths in males (48.4%) were alcohol-related compared to females (32.9%).

CONCLUSIONS

Almost every third injury event in females and in almost every other event in males is alcohol-related, showing that alcohol plays an important part in fatal injuries in females even though it is mostly a male problem.

A 60-year follow-up of alcoholic men

AIMS

To study the course of male alcohol abuse from age 20 to age 70-80 years.

DESIGN

A prospective multi-disciplinary follow-up of two community cohorts of adolescent males from 1940 until the present.

SETTING AND PARTICIPANTS

Two hundred and sixty-eight former Harvard undergraduates (college sample) and 456 non-delinquent, socially disadvantaged Boston adolescents (core city sample).

MEASUREMENTS

Since adolescence these cohorts have been followed by repeated interview, questionnaires and physical examination. The college cohort has been followed until age 80 and the younger core city cohort until age 70. DSM-III criteria were used to ascertain alcohol abuse and alcohol dependence. At some point during their lives, 54 (20%) of the college men and 140 (31%) of the core city men met criteria for alcohol abuse. Outcome categories were mortality, continued alcohol abuse and stable remission.

FINDINGS AND CONCLUSIONS

These socially divergent cohorts resembled each other in four respects. First, by age 70 chronic alcohol dependence was rare; this was due both to death and to stable abstinence. By age 70, 54% of the 72 successfully followed alcohol-dependent core city men had died, 32% were abstinent, 1% were controlled drinkers and only 12% were known to be still abusing alcohol. By age 70, 58% of the 19 successfully followed college alcohol-dependent men had died, 21% were abstinent, 10.5% were controlled drinkers and only 10.5% were known to be still abusing alcohol. Secondly, in both samples alcohol abuse could persist for decades without remission, death or progression to dependence. Thirdly, among both samples prior alcohol dependence and AA attendance were the two best predictors of sustained abstinence. Fourthly, few life-time symptoms of alcohol abuse were the best predictor of sustained return to controlled-drinking.

Alcohol and cardiovascular disease--more than one paradox to consider. Average volume of alcohol consumption, patterns of drinking and risk of coronary heart disease--a review

The effect of average volume of alcohol on coronary heart disease (CHD) is J-shaped in established market economies. Light to moderate drinkers have less risk than abstainers, with heavy drinkers displaying the highest level of risk. This relationship between average volume of alcohol consumption and CHD is modified by different patterns of drinking. Heavy drinking occasions as well as drinking outside meals are related to increased CHD risk, independently of volume of drinking. Beverage type does not seem to have much impact, even though there are some indications that wine is more protective than other forms of alcohol. Physiological mechanisms have been identified to explain this complex relationship between alcohol and CHD. Since patterns of drinking are important in determining CHD risk, they should be included in future epidemiologic studies, together with biomarkers further to test hypotheses about pathways.

Increased mortality among previously apprehended drunken and drugged drivers

Most studies in the field of impaired driving have focused on the hazards imposed on society by the impaired drivers, whereas little attention has been paid to the future outcome of the drivers. The aim of the study was to identify mortality rates and causes of death among drunken and drugged drivers during the years after apprehension. Prospective cohort study on apprehended drunken and drugged drivers, follow-up period: 7.5 years, outcome variable: death. Apprehended drivers 20-39 years old who provided samples positive for alcohol (n=2531) or drugs other than alcohol (n=918) constituting the total national samples of these two driver categories in 1992. The mortality rate among male drunken drivers was higher than in an age-matched Norwegian population (standardised mortality ratio, SMR=3.7 (95% Cl 2.9-4.7). The SMR for drugged drivers was 18.1 (14.9-21.8) for men and 27.9 (14.4-48.8) for women. In a subgroup of male drugged drivers using heroin, SMR was 39.8 (28.8-53.6). The dominant causes of death among drunken and drugged drivers were drug poisoning/overdose, accidents and suicide. Apprehension for drunken or drugged driving and subsequent analytical verification, is an indicator of increased risk of future premature death in the age group 20-39 years, particularly for drugged drivers. To our knowledge this is a new finding, and studies to confirm it should be carried out in other countries. If verified, the results should lead to the consideration of new public health approaches towards apprehended impaired drivers.

Excess alcohol consumption and health outcomes: a 6-year follow-up of men over age 50 from the health and retirement study

AIMS

This study examined the association of problem drinking history and alcohol consumption with the onset of several health conditions and death over a 6-year follow-up period.

SETTING

We analyzed two waves of longitudinal data on men over 50 who participated in the Health and Retirement Study, a nationally representative sample of people aged 51-61 and their spouses living in the United States in 1992.

MEASUREMENTS

Five types of health outcomes--mortality, general health, functional status, cognitive status, and mental health--were examined. Drinking categories were based on average drinks per day (0, <1, 1-2, 3-4, 5+), with 5 + defined as 'very heavy drinking'. Problem drinking history was identified as 2+ affirmative responses to the CAGE questionnaire. We controlled for smoking and other factors at baseline.

FINDINGS

Over the 6-year follow-up period, very heavy drinking at baseline quadrupled the risk of developing functional impairments (OR: 4.21 95%, CI: 1.67, 10.61). A problem drinking history increased the onset of depression (OR: 1.67 95% CI: 1.02, 2.74), psychiatric problems (OR: 2.15 95% CI: 1.47, 3.13) and memory problems (OR: 1.71 95% CI: 1.14, 2.56). Heavy drinking among mature adults was not associated with increased incidence of other adverse health events (i.e. angina, cancer, congestive heart failure, diabetes, myocardial infraction, lung disease or stroke).

CONCLUSION

Very heavy drinking and a problem drinking history greatly increased rates of onset of functional impairments, psychiatric problems and memory loss in late middle age for men who had not experienced these impairments at their initial interview.

The relation between alcohol and cardiovascular disease in Eastern Europe: explaining the paradox

BACKGROUND

Recent evidence from Eastern Europe of a positive association between alcohol and cardiovascular disease has challenged the prevailing view that drinking is cardioprotective. Consuming amounts of alcohol comparable to those consumed in France has been linked to detrimental cardiovascular effects. One possibility is that this could be related to the particular consequences of binge drinking, which is common in Russia.

METHODS

A systematic review of literature on the relation between cardiovascular disease and heavy drinking and irregular (binge) drinking.

RESULTS

Most existing reviews of the relation between alcohol and cardiovascular disease have examined the amount drunk per week or month and have not looked at the pattern of drinking. These have consistently shown that alcohol has a cardioprotective effect, even at high levels of consumption. In contrast, studies that have looked at pattern of drinking, either directly, or indirectly, using indicators such as frequency of hangovers or reports of the consequences of drunkenness, have consistently found an increased risk of cardiovascular death, particularly sudden death. A separate review of the physiological basis for a difference between regular heavy drinking and heavy binge drinking demonstrates that the two types of drinking have quite different effects.

CONCLUSION

An association between binge drinking and cardiovascular death meets the standard criteria for causality. It is important that future studies of alcohol related harm examine the pattern of drinking as well as the amount drunk.

"Alcohol dependence" and death: survival analysis of the Baltimore ECA sample from 1981 to 1995

OBJECTIVE

Evidence is provided about the association between "alcohol-use disorders" and the 14-year risk of death in a community sample. Most prior descriptions of this association come from treatment samples.

METHOD

3,481 adult household residents were recruited into the NIMB Baltimore Epidemiologic Catchment Area survey and interviewed in 1981. The Diagnostic Interview Schedule (DIS) was employed to assess alcohol drinking and other drug-taking behaviors, and to determine fulfillment of DSM-III criteria for "alcohol abuse" and/or "dependence" diagnoses. Participants were followed-up in 1993-1996, by which time 24% of the sample had died. Median age of death was estimated for persons with and without alcohol disorders, and for "heavy" and "nonheavy" drinkers. Cox proportional hazards models adjusted for the influence of age, sex, race, "drug-use disorders," and tobacco smoking.

RESULTS

"Alcohol abuse" and/or "dependence" was associated with a higher risk of death and a younger median age of death (adjusted relative risk = 1.3, p = .016). "Heavy" alcohol consumption was also associated with a significantly elevated risk of death. The DIS diagnosis of "alcohol use disorder" helped predict mortality over and above a prediction based solely upon "heavy drinking" (p < .01).

CONCLUSIONS

These findings indicate that the observed increased risk of death associated with "alcohol dependence" is not limited to cases severe enough to have been treated but is also present among cases in the household population.

The positive relationship between alcohol and heart disease in eastern Europe: potential physiological mechanisms

Research into the effect of alcohol on cardiovascular disease has indicated protective effects from moderate consumption. These observations, made in industrialized countries, have influenced policies on alcohol in countries where the situation may be quite different--specifically, where consumption is substantially higher or patterns of drinking are different. In central and eastern Europe and the former Soviet Union, a growing body of epidemiological research indicates a positive rather than negative association between alcohol consumption and cardiovascular deaths, especially sudden cardiac deaths. By means of a systematic review of published work, we examine whether there is a physiological basis for the observed association between alcohol and heart disease seen in eastern Europe, focusing on the effects of high levels of consumption and of irregular or binge drinking. In binge drinkers, cardioprotective changes in high-density lipoproteins are not seen, and adverse changes in low-density lipoproteins are acquired. Irregular drinking is associated with an increased risk of thrombosis, occurring after cessation of drinking. It predisposes both to histological changes in the myocardium and conducting system and to a reduction in the threshold for ventricular fibrillation. Measures of frequency as well as quantity of consumption should be included in epidemiological studies. Taken with the epidemiological evidence emerging from eastern Europe, these observations have important implications for estimates of the burden of disease attributable to alcohol.