Cerebral dysfunction in alcoholism related to mortality and long term social adjustment

All-cause and cause-specific mortality rates of patients treated for alcohol use disorders: A meta-analysis

BACKGROUND

Although alcohol use disorders (AUDs) are known to increase the relative risk of all-cause and some cause-specific mortality, the absolute mortality rates of the AUD population are unknown. Such knowledge would benefit planners of the provision of services for this population, including in prioritizing the identification and/or treatment of diseases likely to cause their death.

METHODS

We conducted a systematic review of studies in English, reporting the cause-specific mortality rates among people treated for AUDs. Number of deaths by cause and total person-years of follow-up were extracted. All-cause and cause-specific mortality rates per 1000 person-years were meta-analyzed assuming random effects.

RESULTS

Thirty-one studies were included. Participants were mainly middle-aged males. The quality of studies was generally good. A total of 6768 all-cause deaths in 276,990.7 person-years of follow-up (36,375 patients) were recorded, and the pooled all-cause mortality rate was 27.67/1000 person-years (py) (95% confidence interval [CI]: 23.9, 32.04). The most common cause of death in the AUD population was cardiovascular disease (CVD) (6.9/1000 py; 95% CI: 5.61, 8.49), followed by gastrointestinal deaths (5.63/1000 py; 95% CI: 4.1, 7.74), unnatural deaths (4.95/1000 py; 95% CI: 4.01, 6.09)), neoplasms, respiratory diseases, and substance use disorders.

CONCLUSIONS

Patients with AUDs have increased rates of all-cause and cause-specific mortality compared with the general population. Like the general population, they are most likely to die of CVD. In contrast to the general population, gastrointestinal and unnatural deaths are the next most common causes of death. We believe these facts should be considered when planning health care services for patients with AUDs.

Alcoholics committed to treatment: a prospective long-term study of behavioral characteristics, mortality, and social adjustment

Three hundred eighty-three alcoholics, who had at least once been ordered supervision or compulsory treatment at an institution for alcoholics by the Temperance Board, were compared with 383 other alcoholics matched for age and sex. All the alcoholics were first admitted to the Department of Psychiatry, University Hospital, Lund, during the years 1949 to 1969 and followed up until January 1, 1981. They were systematically rated concerning symptoms and etiological factors at first admission. According to a stepwise logistic regression analysis, the following initial symptoms were positively associated with later compulsory treatment: slight cerebral dysfunction/personality change, antisociality/criminality, and impaired social and work performance. Social pressure/responsibility/conflict, slight depression, and continuous drinking were positively associated with the controls. There were 168 deaths in the compulsory treatment group and 124 in the control group (p less than 0.01). The excess deaths in the compulsory treatment group were mainly caused by accidents, poisoning, and violence (21 cases) and sudden cardiac death (10 cases), while there were no differences concerning alcohol-related neoplasms and liver cirrhosis. The compulsory treatment group had a worse long-term social adjustment. The findings indicate that compulsory treatment was related to behavioral patterns showing a stability over time, supporting the validity of subclassification of alcoholics using social data.

Suicide in alcoholism. A prospective study of 55 cases with autopsy findings

In a previous paper we reported prospective ratings for 88 alcoholic suicides. At the initial admission they had more often signs of peptic ulcer, depression, dysphoria and brittleness than other alcoholics. In 55 of these alcoholics an autopsy was performed at the Department of Forensic Medicine, University Hospital, Lund. In 37 cases the blood alcohol level was measured (at time of death). Alcoholics with brittleness had more often blood alcohol levels over 0.1% than others, and alcoholics with dysphoria more often negative tests even if the suicide generally was associated with previous drinking. Concerning the blood alcohol level alcoholics with peptic ulcer did not differ from the others. Alcoholics with initial depression had more often previous suicide attempts. Twenty (36%) of the alcoholics had experienced a personal loss during the year preceding the suicide. The possible implications of the findings for suicide prevention strategies is discussed.

Suicide in psychiatric patients. A prospective study of 67 cases without initial signs of severe depression or alcoholism

All cases from the county, who were subjected to post-mortem examination at the Department of Forensic Medicine, University of Lund with a diagnosis of suicide during 1949-1984, were compared with the inpatient register at the Department of Psychiatry, University Hospital, Lund during 1949-1969. During these years all patients were rated at discharge with a multidimensional schedule. All patients with initial ratings of severe depression/melancholia and alcoholism were analyzed separately and excluded from the present sample. The ratings of the suicide cases were compared with those of 8,046 other inpatients. There were 67 suicide cases, 36 men and 31 women. The suicide cases had higher frequencies of the item easily led/dependent/immature personality (34% versus 18%) and of attempted suicides (19% versus 8%). There were no differences in ratings of symptoms as slight depression and anxiety or of situational factors. Attempted suicide was related to suicides early in the course, while easily led/dependent/immature was not so related. At the time of the suicide there was a higher frequency of never married and a lower frequency of married subjects in the present series compared with suicides in severe depression/melancholia and alcoholism.

Mortality in severe depression. A prospective study including 103 suicides

Twelve hundred and six psychiatric in-patients, 506 men and 700 women, with severe depression/melancholia were rated at discharge with a multi-dimensional diagnostic schedule during 1956-1969. The sample was followed up until December 31, 1983. A total of 476 deaths were recorded including 103 suicides. Suicides and to a small proportion diseases of the nervous system constituted the total excess mortality in unipolar disorders. In bipolar disorders there was also an increased mortality from physical disorders, while the suicide frequency was lower (9% versus 4%). Male suicides had higher initial ratings for the items brittle, sensitive, marital problems, acute onset and lower ratings for psychomotor retardation than other men. Female suicides had a higher frequency of attempted suicides than other women. Acute onset and attempted suicide were associated with suicides early in the course contrary to the other differentiating items. The suicide frequency was similar in admissions during 1956-1962 compared with those during 1963-1969.

Ageing and recovery from alcoholism

Fifty-five dependent (DSM-III) male alcoholics, chosen for good social adjustment, were personally followed up about 20 years after their first admission to hospital. The conditions of all the alcoholics were evaluated with a multidimensional diagnostic schedule when first admitted. At the follow-up, 11 were abstainers, 11 reported a change to social drinking via abstinence, and 10 reported a change to social drinking by gradual stages. Improvement after the age of 45 was mainly due to gradual change to social drinking. This type of improvement was in half of the cases attributed to a decreased tolerance for alcohol. In the present sample, there were no indications of any relationship between premature ageing and gradual change to social drinking. It is hypothesised that physiological processes of normal ageing with concomitant changes in reactions to alcohol may be of importance for remission from alcoholism in middle-aged and older alcoholics. The relationships of personality, social factors and the degree of alcohol-dependence to patterns of successful long-term adjustment are discussed.

Suicide in male alcoholics with peptic ulcers

Eighty-seven male alcoholics with peptic ulcers and 913 without peptic ulcers were first admitted to the Department of Psychiatry of Lund, Sweden during the period 1956-1969. In the initial ratings rigidity/perfectionism, strain/tenseness, sleep disturbances, the asthenic syndrome, and heredity for alcoholism/personality disturbances/suicide were more frequent in the peptic ulcer group than in the others. Patients with peptic ulcers were more often married and less often unmarried or showed antisocial/criminal indications of antisociality/criminality. A follow-up by records was performed on January 1, 1981. Seventeen percent in the peptic ulcer group and 6% in the other group had committed suicide (p less than 0.001). Mortality (suicides excluded) was similar in the two groups as was the social adjustment among the survivors. Within the peptic ulcer group strain/tenseness was significantly related to future suicide, while operation, heredity, and rigidity/perfectionism were not.

Successfully adjusted alcoholics lost to long-term follow-up. A prospective study

In a two-decade personal follow-up of male alcoholics who had been assessed by a multidimensional diagnostic schedule when first admitted to hospital, the attrition rate was somewhat higher (14%) in a sample chosen for good social adjustment (N = 70) than in a comparison group (N = 35) of subjects with a disability pension (9%). In the good social adjustment sample, outcome status did not differ between subjects causing follow-up difficulties compared with the others. In both samples there was a higher frequency of personality disturbance with lack of internal control of behaviour (initial ratings) in subjects who were lost or caused other follow-up difficulties compared with the others (P less than 0.05). Among the socially well adjusted alcoholics the frequency of psychopathic behaviour when first admitted was higher in the lost than in the interviewed subjects (P less than 0.001).