A follow-up study on alcoholics with and without co-existing affective disorder

The prevalence of psychiatric comorbidity and its relationship to the severity of alcohol dependence in the population of rural south India

Background

Many international studies have reported a high prevalence of psychiatric comorbidity in alcohol-dependent individuals and highlighted the clinical, prognostic, and treatment implications of such findings. However, there is a paucity of such information within the context of India. This study investigates the prevalence of psychiatric comorbidity in treatment-seeking alcohol-dependent individuals and its relationship with the severity of this dependence.

Result

This was a prevalence study conducted for a period of 1 year. Patients were identified from Mahbubnagar, a local area in rural south India, and recruited at outpatient deaddiction clinic of SVS hosital. Application for research ethics approval was approved. A consecutive sample of 100 inpatients diagnosed with alcohol dependence syndrome was recruited. The Mini-International Neuropsychiatric Interview was used to assess psychiatric comorbidity 2 weeks after detoxification. The severity of dependence was judged using the Severity of Alcohol Dependence questionnaire. One-hundred (male, n = 65; female, n = 35) alcohol-dependent patients were recruited. The mean age of participants was 41.9 (SD = 9.3) years. Participants (n = 33, 33%) had a co-occurring psychiatric disorder, the commonest being mood disorder (n = 18), which sub-divided into major depressive disorder (n = 8), dysthymia (n = 5), manic episode (n = 3), and hypomanic episode (n = 2), followed by anxiety disorders (n = 11) and then psychotic disorder (n = 4). The comorbid psychiatric disorders were significantly associated with the severity of dependence (p = 0.001) and longer duration of alcohol (p = 0.003) use.

Conclusion

This result emphasizes the need to thoroughly assess patients for possible under-identified dual diagnosis and provide treatments accordingly.

“I know if I drink I won’t feel anything”: substance use relapse among depressed women leaving prison

PURPOSE

The purpose of this paper is to explore treatment needs and factors contributing to engagement in substance use and sobriety among women with co-occurring substance use and major depressive disorders (MDDs) as they return to the community from prison.

DESIGN/METHODOLOGY/APPROACH

The paper used qualitative methods to evaluate the perspectives of 15 women with co-occurring substance use and MDDs on the circumstances surrounding their relapse and recovery episodes following release from a US prison. Women were recruited in prison; qualitative data were collected using semi-structured interviews conducted after prison release and were analyzed using grounded theory analysis. Survey data from 39 participants supplemented qualitative findings.

FINDINGS

Results indicated that relationship, emotion, and mental health factors influenced women's first post-prison substance use. Women attributed episodes of recovery to sober and social support, treatment, and building on recovery work done in prison. However, they described a need for comprehensive pre-release planning and post-release treatment that would address mental health, family, and housing/employment and more actively assist them in overcoming barriers to care.

PRACTICAL IMPLICATIONS

In-prison and aftercare treatment should help depressed, substance using women prisoners reduce or manage negative affect, improve relationships, and obtain active and comprehensive transitional support.

ORIGINALITY/VALUE

Women with co-occurring mental health and substance use disorders are a high-risk population for negative post-release outcomes, but limited information exists regarding the processes by which they relapse or retain recovery after release from prison. Findings inform treatment and aftercare development efforts.

Pilot study of treatment for major depression among women prisoners with substance use disorder

This study, the largest randomized controlled trial of treatment for major depressive disorder (MDD) in an incarcerated population to date, wave-randomized 38 incarcerated women (6 waves) with MDD who were attending prison substance use treatment to adjunctive group interpersonal psychotherapy (IPT) for MDD or to an attention-matched control condition. Intent-to-treat analyses found that IPT participants had significantly lower depressive symptoms at the end of 8 weeks of in-prison treatment than did control participants. Control participants improved later, after prison release. IPT's rapid effect on MDD within prison may reduce serious in-prison consequences of MDD.

Confirmation of prior evidence of genetic susceptibility to alcoholism in a genome-wide association study of comorbid alcoholism and bipolar disorder

OBJECTIVES

Alcoholism and affective disorders are both strongly comorbid and heritable. We have investigated the genetic comorbidity between bipolar affective disorder and alcoholism.

METHODS

A genome-wide allelic association study of 506 patients from the University College London bipolar disorder case-control sample and 510 ancestrally matched supernormal controls. One hundred forty-three of the bipolar patients fulfilled the Research Diagnostic Criteria diagnosis of alcoholism. A total of 372 193 single nucleotide polymorphisms (SNPs) were genotyped. Genes previously shown to be associated with alcoholism and addiction phenotypes were then tested for association in the bipolar alcoholic sample using gene-wise permutation tests of all SNPs genotyped within a 50-kb region flanking each gene.

RESULTS

Several central nervous system genes showed significant (P<0.05) gene-wise evidence of association with bipolar alcoholism. The genes implicated, which replicated genes previously shown to be associated with alcoholism were: cadherin 11, collagen type 11 α2, neuromedin U receptor 2, exportin7, and semaphorin-associated protein 5A. The SNPs most strongly implicated in bipolar alcoholism, but, which did not meet conventional genome-wide significance criteria were the insulin-like growth factor-binding protein 7, carboxypeptidase O, cerebellin 2, and the cadherin 12 genes.

CONCLUSION

We have confirmed the role of some genes previously shown to be associated with alcoholism in the comorbid bipolar alcoholism subgroup. In this subgroup, bipolar disorder may lower the threshold for the phenotypic expression of these alcoholism susceptibility genes. We also show that some genes may independently increase susceptibility to affective disorder and alcoholism.

Effects of major depression on crack use and arrests among women in drug court

AIMS

We examined whether a current major depressive episode (MDE) at baseline predicted crack use and arrests at follow-up among women enrolled in drug court.

DESIGN

Primary analyses used zero-inflated Poisson (ZIP) and zero-inflated negative binomial (ZINB) regression analyses to predict both yes/no and number of (i) days of crack use and (ii) arrests at 4-month follow-up from current (30-day) MDE at baseline. Secondary analyses addressed risk conferred by current versus past MDE at baseline.

SETTING/PARTICIPANTS

Participants were 261 women in drug court.

MEASUREMENTS

MDE was assessed using the Diagnostic Interview Schedule. Days using crack and number of arrests were assessed using the Washington University Risk Behavior Assessment for Women.

FINDINGS

Having a current MDE at baseline predicted likelihood of crack use at follow-up, but not days of crack use among those who used. Current MDE at baseline did not predict presence or number of arrests at the 4-month follow-up. Women with current MDE at baseline were more likely to be using crack at follow-up than were those with recent (31+ days to 12 months) but not current MDE (odds ratio = 5.71); past MDE at baseline did not increase risk of crack use.

CONCLUSIONS

Predictors of any versus no crack use or arrests appear to differ from predictors of frequency of these behaviors. Current major depression, but not past major depression, appears to be associated with increased risk of crack use among women attending drug court.

Meta-analysis of depression and substance use among individuals with alcohol use disorders

The relationships of depression with alcohol and drug use and impairment were examined. Additional analyses were conducted to examine moderators of these associations. Empirical reports on adults with alcohol abuse or dependence published in English in peer-reviewed journals since 1986 that contained data on depression and substance use variable(s) were obtained using a systematic search. The search yielded 74 studies including 58 reports from clinical venues, 10 that were community based, and 6 with subjects from both settings. As hypothesized, the analyses showed that depression is associated with concurrent alcohol use and impairment and drug use and impairment. Effect sizes were small. Depression was also related to future alcohol use and impairment, an earlier age of onset of an alcohol use disorder, and higher treatment participation. Age moderated the association between depression and alcohol use and impairment such that the association was stronger in older samples.

Suicidal behaviour among alcohol-dependent Danes attending outpatient treatment

The association between alcohol dependence and suicidal behaviour is well established and patients with suicidal behaviour in treatment for alcohol dependence present a considerable challenge for clinical services. The aim of this study is to identify risk factors for suicide attempts and to evaluate the outcome of treatment in patients in treatment for alcohol dependence. Semi-structured, detailed interviews were administered at baseline and at three sequential follow-up interviews with a large sample of 1692 patients at an outpatient treatment centre in the county of Funen in Denmark. Characteristics of, predictors for and outcome among suicidal patients were studied. Alcohol-dependent patients with a history of suicide attempts were found to constitute a highly selected group in alcohol abuse treatment as they often had a more severe course of alcohol dependence, were unemployed, younger, were more often lowly educated, and had more physical and psychiatric problems. Traumatic childhood experience related to physical or sexual abuse was found as a major predictor for suicidal behaviour among alcohol-dependent patients. We found no significant difference in the effect of treatment in patients with and without suicidal behaviour. These results support the hypothesis that alcohol-dependent patients with a history of suicide attempts are a selected group in respect to a number of demographical and psychosocial factors, but we found no difference in the outcome of treatment. This may imply that suicidal patients in treatment for alcohol abuse are treated effectively within the present treatment settings.

Positron emission tomography study of regional brain metabolic responses to a serotonergic challenge in major depressive disorder with and without comorbid lifetime alcohol dependence

This is the first study contrasting regional glucose metabolic rate (rCMRglu) responses to a serotonergic challenge in major depressive disorder (MDD) with and without comorbid alcohol dependence. In a university hospital, patients with MDD without a history of alcohol dependence (MDD only) and patients with MDD and comorbid alcohol dependence (MDD/ALC) were enrolled in this study. Subjects with comorbid borderline personality disorder were excluded. A bolus injection of approximately 5 mCi of (18)fluorodeoxyglucose was administered 3 h after the administration of placebo or fenfluramine. We found an anterior medial prefrontal cortical area where MDD/ALC subjects had more severe hypofrontality than MDD only patients. This area encompassed the left medial frontal and left and right anterior cingulate gyri. This group difference disappeared after fenfluramine administration. The fact that the observed group difference disappeared after the fenfluramine challenge suggests that serotonergic mechanisms play a role in the observed differences between the groups.

The relationship of aggression to suicidal behavior in depressed patients with a history of alcoholism

BACKGROUND

Alcoholism and depression are often comorbid. Studies suggest that depressed subjects with alcoholism have more chronic impairment and suicidal behavior than individuals with either diagnosis alone. The reason for higher rate of suicide and suicide attempts in comorbid subjects is uncertain. We explored clinical characteristics that may be associated with this increased suicidality.

METHODS

In all, 219 depressed subjects (n=62 males and n=157 females) without a history of any alcohol or substance use disorder and 129 (n=49 males and n=80 females) depressed individuals with a prior history of alcohol use disorder participated in the study. Demographic and clinical parameters were assessed and recorded.

RESULTS

Depressed subjects with a history of alcoholism had higher lifetime aggression and impulsivity, and were more likely to report a history of childhood abuse, suicide attempts, and tobacco smoking. Depressed suicide ideators with a history of alcoholism had higher suicide ideation scores than depressed suicide ideators without a history of alcoholism. Subjects with a history of alcoholism were younger at the time of the first depressive episode and first hospitalization than those without a history of alcoholism. Logistic regression analysis indicated that alcoholism was significantly associated with smoking and aggression. Suicidal behavior and higher suicidal ideation in depressed subjects with a history of alcoholism might be attributed to higher aggression scores in this group.

CONCLUSION

The greater frequency of suicidal behavior and severity of suicidal ideation in major depression with comorbid alcoholism appears related to associated aggressive traits. Alcoholism, aggression, smoking, and suicide may have a common biological causal substrate.

Context of relapse for substance-dependent adults with and without comorbid psychiatric disorders

OBJECTIVE

This study examined the context of initial posttreatment substance use episodes and 1-year treatment outcomes among substance abusers in relation to Axis I psychiatric diagnoses.

METHOD

Of the 210 adults meeting DSM-III-R diagnostic criteria for a substance use disorder (SUD), 102 also met criteria for mood disorder, posttraumatic stress disorder (PTSD), or both (SUD-PSY). Quarterly face-to-face interviews and monthly telephone contacts were conducted following treatment to ascertain outcomes.

RESULTS

Antecedents of initial posttreatment substance use differed for SUD adults compared to SUD-PSY. Negative affective states preceded posttreatment use episodes more frequently among SUD-PSY participants. The majority of SUD-PSY adults reported intrapersonal/environmental antecedents whereas the majority of SUD adults reported interpersonal antecedents. Compared to SUD adults without an Axis I disorder, the SUD-PSY group was more likely to resume substance use when alone. Participants drank more than twice as much alcohol when relapsing alone compared to those who resumed use with others. Negative affective state prior to initial use was predictive of more subsequent using days for comorbid adults but not SUD adults.

CONCLUSIONS

These findings highlight differences in the process of resuming substance use for substance abusers with concomitant psychiatric disorders compared to SUD adults. Treatment implications are discussed.

Substantial decrease of psychiatric comorbidity in chronic alcoholics upon integrated outpatient treatment - results of a prospective study

It is far from clear how comorbidity changes during alcoholism treatment. This study investigates: (1) the course of comorbid Axis I disorders in chronic alcoholics over 2 years of controlled abstinence in the outpatient long-term intensive therapy for alcoholics (OLITA) and (2) the effect of comorbid Axis I and II disorders in this group of patients on subsequent drinking outcome over a four-year follow-up. This prospective treatment study evaluates psychiatric variables of 89 severely affected chronic alcohol dependent patients on admission (t(1)), month 6 (t(2)), 12 (t(3)) and 24 (t(4)). Drinking outcomes have been analyzed from 1998 to 2002. On admission, 61.8% of the patients met criteria for a comorbid Axis I disorder, 63.2% for a comorbid personality disorder. Axis I disorders remit from t(1) (59.0% ill), t(2) (38.5%), t(3) (28.2%) to t(4) (12.8%) (p < 0.0001). Anxiety disorders remit more slowly from t(1) (43.6%) to t(3) (20.5%, p = 0.0086), whereas mood disorders remit early between t(1) (23.1%) and t(2) (5.1%, p = 0.0387) with a slight transient increase at t(3) (10.3%). During the four-year follow-up, the cumulative probability of not having relapsed amounts to 0.59. Two predictors have a strong negative impact on abstinence probability: number of inpatient detoxifications (p = 0.0013) and personality disorders (p = 0.0106). The present study demonstrates a striking remission of comorbid Axis I disorders upon abstinence during comprehensive long-term outpatient alcoholism treatment. The presence of an Axis II rather than an Axis I disorder on admission strongly predicts drinking outcome over a four-year follow-up.

Psychiatric comorbidity and substance use treatment outcomes of adolescents

Treatment outcomes of 126 adolescents (13-18 years old) with comorbid substance use disorders (SUDs) and Axis I psychiatric disorders (mood, anxiety, conduct, and attention-deficit/hyperactivity disorders) were compared to 81 SUD adolescents with no additional Axis I disorder. Participants completed structured interviews and symptom measures while participating in an adolescent treatment program and at 6 months following treatment. Results indicated that comorbid youth received more treatment during the outcome period; despite this, more comorbid SUD-Axis I disordered adolescents used substances following treatment than SUD-only youth, even after controlling for socioeconomic status and ethnicity. Among comorbid youth, internalizing disordered adolescents were less likely to use substances during the follow-up period, and externalizing disordered youth returned to substance use most rapidly after discharge from treatment.

Lower CSF homovanillic acid levels in depressed patients with a history of alcoholism

Major depression and alcoholism are often comorbid, resulting in more impairment and more suicidal behavior compared with either diagnosis alone. This study compared clinical features and cerebrospinal fluid (CSF) monoamine metabolites in depressed subjects with and without a history of alcoholism and healthy volunteers. We hypothesized that depressed subjects with a history of alcoholism would be more aggressive, impulsive, and suicidal than depressed subjects without a history of alcoholism, and would have lower CSF monoamine metabolite levels. We compared 63 subjects with a current major depressive episode (MDE) and a history of alcoholism, 72 subjects with a current MDE but without a history of alcoholism, and 22 healthy volunteers. Participants with a history of alcoholism were in remission for at least 6 months. All subjects were free from prescribed medications known to affect brain serotonin, dopamine, or norepinephrine systems for a minimum of 14 days. Depressive symptoms, lifetime aggression, impulsivity, Axis II disorders, and suicidal behavior were assessed. CSF was sampled and homovanillic acid (HVA), 5-hydroxyindolacetic acid (5-HIAA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) were assayed by high-performance lipid chromatography with electrochemical detection. Depressed subjects with a history of alcoholism did not differ from depressed subjects without a history of alcoholism in current severity of depressive symptoms, or in past suicidal behavior. Depressed subjects with a history of alcoholism had lower CSF HVA levels, and higher lifetime aggression and current suicide ideation scale scores and were more likely to be tobacco smokers compared with depressed subjects without a history of alcoholism. Low HVA was present after adjustment for sex, aggression and depression scores, cigarette smoking, antisocial and borderline personality disorders, psychomotor retardation, and delusions. Controls had CSF HVA levels intermediate between the two depressed groups. We found no group difference in CSF 5-HIAA and MHPG levels. In individuals with current MDE, those with a history of comorbid alcoholism had lower CSF HVA levels compared with those without a history of alcoholism. Low CSF HVA suggests that impaired dopaminergic activity is associated with a history of alcoholism in persons with current MDE.

Effects of heavy alcohol consumption on the cardiovascular system may be mediated in part by the influence of alcohol-induced depression on the immune system

The harmful effects of heavy alcohol use are well-documented and wide-ranging. Heavy drinking may cause or exacerbate cardiovascular disorders. The author suggests that effects of heavy alcohol consumption on the cardiovascular system may be mediated in part by the influence of alcohol-induced depression on the immune system. This hypothesis is based on the following data: (1) alcohol misuse may cause or exacerbate depression; (2) depressive disorders are associated with increased incidence, morbidity, and mortality of cardiovascular disorders; (3) the immune system may mediate effects of depressive disorders on the cardiovascular system. Further studies are needed to clarify the etiopathogenesis of alcohol-related disorders and develop new treatment modalities.

Substance abuse and bipolar comorbidity

Bipolar disorder and substance abuse commonly co-occur. In fact, as many as 50% of individuals with bipolar disorder have been found to have a lifetime history of substance abuse or dependence. This article discusses the very important comorbidity of bipolar disorder as it is complicated by substance abuse, focusing on the prevalence, course, diagnostic considerations and treatment.

Depression among cocaine abusers in treatment: relation to cocaine and alcohol use and treatment outcome

OBJECTIVE

The authors investigated the theoretical and clinical role of depression among cocaine abusers in treatment.

METHOD

Eighty-nine cocaine-abusing patients underwent 2 weeks of substance abuse treatment. Posttreatment major depressive disorder, depressive symptoms before and after substance abuse treatment, and alcohol diagnoses were assessed and their relation to pretreatment substance use, cravings in high-risk situations, and 3-month follow-up status was examined.

RESULTS

High rates of major depressive disorder were found but were unrelated to pretreatment substance use. The decrease in depressive symptoms during treatment was independent of major depressive disorder or alcohol diagnoses and predicted treatment attrition. Higher levels of depressive symptoms during treatment were associated with greater urge to use cocaine, alcohol, and other drugs in high-risk situations. Concurrent major depressive disorder and depressive symptoms did not predict cocaine use at follow-up. However, patients who had an alcohol relapse episode experienced more depressive symptoms during treatment than did those who abstained.

CONCLUSIONS

The results highlight the relationship of depression to alcohol use among cocaine abusers and suggest a need for further studies of the association between depression and substance use disorders.

Cognitive-behavioral treatment for depression in alcoholism

Alcoholics with depressive symptoms score > or = 10 on the Beck Depression Inventory (A.T. Beck, C. H. Ward, M. Mendelson, J. Mock, & J. Erbaugh, 1961) received 8 individual sessions of cognitive-behavioral treatment for depression (CBT-D, n = 19) or a relaxation training control (RTC; n = 16) plus standard alcohol treatment. CBT-D patients had greater reductions in somatic depressive symptoms and depressed and anxious mood than RTC patients during treatment. Patients receiving CBT-D had a greater percentage of days abstinent but not greater overall abstinence or fewer drinks per day during the first 3-month follow-up. However, between the 3- and 6-month follow-ups, CBT-D patients had significantly better alcohol use outcomes on total abstinence (47% vs. 13%), percent days abstinent (90.5% vs. 68.3%), and drinks per day (0.46 vs. 5.71). Theoretical and clinical implications of using CBT-D in alcohol treatment are discussed.

Five-year course of major depression: effects of comorbid alcoholism

Some patients enter psychiatric treatment with clear cases of both major depression and alcoholism. While assumptions are often made about the relationships of these two conditions, little empirical evidence exists on the effects of sustained remissions in alcoholism on sustained remissions in depression. 127 patients with both disorders at treatment entry were studied over a 5-year period. Survival analyses with time-dependent covariates indicating alcoholism status were used to investigate remissions and relapses in major depression. Remission in alcoholism strongly and significantly increased the chances of remission in depression and were also related to reduced chances of depression relapse, although at a weaker level.

The relationship between DSM-IV alcohol use disorders and DSM-IV major depression: examination of the primary-secondary distinction in a general population sample

This study examined the primary-secondary distinction with respect to DSM-IV alcohol use disorders and major depression in a large representative sample of the USA. Primary, secondary and concurrent depressives (i.e. the comorbid groups), respondents classified with major depression only and respondents classified with alcohol use disorders only were compared on a large number of sociodemographic, alcohol-related, depression-related and drug-related variables. Results were at variance with a majority of findings from the treatment literature with regard to familial aggregation of alcohol use disorders and sociodemographic, alcohol and depression profiles. Implications of the results are discussed in terms of the diagnostic and prognostic significance of the primary-secondary distinction.

Assessing gender interactions in the prediction of mortality in alcoholic men and women: a 20-year follow-up study

This study investigates the predictors of mortality in 259 male and female alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for > 20 years. The findings showed that, in addition to age, marital status, medical complications, and non-antisocial personality comorbidity were important independent predictors of time to death. Data pointed to gender interactions, in that marital disruption tended to be a stronger predictor of mortality in men, and delirium tremens tended to be a stronger predictor of mortality in women. Knowing and understanding that certain events and processes may differentially affect the survival of male and female alcoholics will allow for the development of more individualized and gender-specific therapeutic interventions.

Diagnosis of depression in alcohol dependence: changes in prevalence with drinking status

BACKGROUND

Depression and alcohol dependence are frequently found to co-exist but the relationship between these disorders requires further elucidation. This study tested several hypotheses related to the relevance of whether the diagnosis of depression was made before admission or after detoxification in the current episode for those with alcohol dependence.

METHOD

The Schedule for Affective Disorders and Schizophrenia (SADS) was administered to obtain Research Diagnostic Criteria (RDC) on 82 randomly selected alcohol dependent in-patients. Alcohol-related (Severity of Alcohol Dependence Questionnaire (SADQ), alcohol consumption and alcohol-related problems), socio-demographic variables and treatment for depression were assessed.

RESULTS

For the episode of drinking which led to admission, a diagnosis of major depression was found in the majority of patients (67%). Once detoxification from alcohol took place, only the minority (13%) met criteria for major depression.

CONCLUSIONS

It is suggested that depression is largely associated with the episode of drinking which led to admission in patients who are dependent on alcohol and may be due to the effect of chronic alcohol intoxication. Socio-demographic and alcohol-related characteristics appear to bear little relation to the presence of depression. Clinicians exercise appropriate judgement in not prescribing antidepressant treatments to patients whose depression may remit with abstinence from alcohol.

Differences in recent life events between alcoholic and depressive nonalcoholic suicides

The purpose of this study was to investigate the main differences in recent life events preceding suicide between alcoholic and depressive nonalcoholic suicide victims, how much these differences were sex- and age-dependent, and how social support varied between these groups. Using the psychological autopsy method, retrospective best-estimate diagnoses by DSM-III-R criteria were assigned to a randomized 16.4% sample (n = 229) of suicide victims drawn from a 1-year total nationwide suicide population (n = 1,397) in Finland. Life events during the last 3 months (32 items) and social support (6 items) of 75 suicide victims with alcohol abuse/dependence diagnoses were compared with those of 69 nonalcoholic depressive victims. Among male suicides, the alcoholics had experienced more separations and family discord, financial trouble, and unemployment, whereas the depressives had experienced more somatic illness. Among females, adverse interpersonal events had been common in both alcoholic and depressive victims. Among the alcoholics, unlike the depressives, the number of adverse interpersonal life events had not diminished with increasing age. Living alone had been twice as common among the alcoholic suicides and, in these cases, recent separation, unemployment, and financial trouble were remarkably common, suggesting a concurrent stressor effect. Our results confirm and extend the earlier findings of excess interpersonal stressors among alcoholic suicides compared with depressive suicides. The findings suggest that multiple adverse life events and living alone need to be taken into account in clinical practice when assessing psychosocial stress and suicidal danger in alcoholism.

Level of education and alcohol abuse and dependence in adulthood: a further inquiry

OBJECTIVES

Prospectively gathered data were used to reexamine and to strengthen previously described observations about education and the risk of alcohol abuse and dependence. The hypothesis was that individuals who dropped out of high school and those who entered college but failed to get a college degree might be at increased risk for an alcohol disorder.

METHODS

Study subjects were selected between 1980 and 1984 by taking probability samples of roughly 3000 adult household residents at each of the five Epidemiologic Catchment Area Program survey sites. To assess the occurrence of psychiatric conditions, staff administered the Diagnostic Interview Schedule soon after sampling and again at follow-up, roughly 1 year later.

RESULTS

Individuals who had dropped out of high school were 6.34 times more likely to develop alcohol abuse or dependence than were individuals with a college degree. For those who had entered college but failed to achieve a degree, the estimated relative risk was 3.01. To extend these analyses, estimates for annual incidence were calculated, and an exploratory evaluation of interaction is presented.

CONCLUSIONS

If these findings can be replicated, they should help identify subgroups at higher risk for the development of alcohol disorders.

Primary depressives with secondary alcoholism compared with alcoholics and depressives

While a subset of depressed patients are believed to "self-medicate" their depression with alcohol, there are no studies comparing the phenomenological and diagnostic characteristics of patients with primary depression and secondary alcoholism with those of patients with depression or alcoholism alone. In this study, we compared 11 patients from each of these three diagnostic groups in terms of past history and current clinical presentation. The patients were matched for age, sex, and level of function. Comorbid patients were most likely to meet criteria for sedative dependence and panic disorder, and had higher scores on the Hamilton Anxiety Scale. In addition, they scored higher on a hypomania scale and had more first-degree relatives with a history of drug abuse.

The depressed alcoholic. Clinical features and medical management

A relationship between depression and alcoholism has long been postulated. A review of prior research studies reveals that though patients with depression do not appear to develop alcoholism to any great extent, recently detoxified alcoholics have a depressive syndrome about 20% of the time. This cannot be accounted for readily from data on family studies or genetic studies, which generally suggest that alcoholism and depression are two independent illnesses, albeit both quite common. Clinically, depressed alcoholics resemble alcoholics more than they resemble depressives. The clinical course of depression when it coexists with alcoholism is generally benign and self-limited, with most patients becoming euthymic over the course of 2-4 weeks without specific antidepressant treatment. In some depressed alcoholics, however, a more chronic depression persists, and may predict a worse outcome for the alcoholism. Treatment of depression in alcoholics should be initially conservative. Tricyclic and other antidepressants should be used with extreme care as they may potentiate toxic effects of alcohol.