Alcohol and Alcoholism Advance Access originally published online on February 21, 2006
Alcohol and Alcoholism 2006 41(3):315-320; doi:10.1093/alcalc/agh240
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CURRENTLY ACTIVE AND REMITTED ALCOHOL DEPENDENCE IN A NATIONWIDE ADULT GENERAL POPULATION—RESULTS FROM THE FINNISH HEALTH 2000 STUDY
1 Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland, 2 Health and Social Services Division, STAKES (National Research and Development Centre for Welfare and Health), Helsinki, Finland, 3 Department of Psychiatry, University of Helsinki, Finland and 4 Finnish Foundation for Alcohol Studies, PO Box 220, 00531 Helsinki, Finland
* Author to whom correspondence should be addressed at: Department of Mental Health and Alcohol Research, National Public Health Institute, Mannerheimintie 166, FIN-00300 Helsinki, Finland. Tel.: +358 9 47448213; Fax: +358 9 47448478; E-mail: sami.pirkola{at}ktl.fi
(Received 17 September 2005; first review notified 15 October 2005; in final revised form 21 October 2005; accepted 22 October 2005)
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Aims: To study the factors relating to remission from alcohol dependence in the general population. Methods: Within a representative, cross-sectional general population sample aged 30 years or more, the characteristics of subjects remitted from alcohol dependence were examined by comparisons with actively alcohol-dependent subjects. Results: The overall lifetime prevalence of alcohol dependence was 7.9%. Comorbid depressive and anxiety disorders were diagnosed in 22% of the actively alcohol-dependent and in 19% of the remitted subjects. There were few sociodemographic, clinical or childhood-related factors differentiating the two groups of subjects. Of comorbid mental disorders, social phobia (6% vs 1%) and dysthymia (7% vs 3%) were more common among the actively alcohol-dependent, whereas other common disorders were equally common for both active and remitted alcohol dependence. Health care or other service use for alcohol problems within the previous 12 months was more frequent among the actively dependent (16% vs 4%), and the same was true for health care use for mental health problems (17% vs 8%). Any service use in the previous year for either type of problem was more common among the actively dependent than the remitted (26% vs 13%). Conclusions: In an unselected setting, only comorbid social phobia and dysthymia differentiated active alcohol dependence from a remitted state, suggesting either that they are obstacles to remission from an active state, explaining why some alcohol-dependent individuals are unable to recover, or that their symptoms are maintained by excessive alcohol use. The actively alcohol-dependent used both substance use services and mental health services more often than the remitted subjects, possibly due to needs generated by their alcohol problem. Comorbid psychopathology should be considered when developing treatment options for alcohol dependence.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Alcohol dependence is among the most frequent mental disorders and a major source of comorbidity in association with affective, anxiety, and personality disorders (Kessler et al., 1994
; Grant et al., 2004). Its degrading impact on both psychiatric morbidity and treatment management is considered highly important (Kessler et al., 1996; Grant et al., 2004).
Remission is often determined as an alcohol-dependent subject's symptom recovery for at least a year, although a substantial proportion of remitted alcohol-dependent subjects continue moderate drinking after remission (Sobell et al., 1996). Total abstinence, however, is thought to be an essential goal in the treatment of relatively severe forms of alcohol dependence (APA, 1995; Garbutt et al., 1999). Evidence on factors that associate with remission from alcohol dependence is inconsistent, and does not point to whether these factors have a predisposition to, or are consequences of, the remitted state. The majority of recoveries from alcohol dependence are achieved without formal help or treatment (Sobell et al., 1996). A less severe form of dependence, better psychosocial support, and a ‘hitting rock-bottom’ kind of deterioration or another kind of turning point experience are among the characteristics reported to associate with remission from alcohol dependence (Klingemann, 1991; Bischof et al., 2001). Relatively few factors have been reported to predict abstinence or remission from alcohol dependence in the few long-term follow-up studies available on men dependent on or abusing alcohol men (Ojesjo et al., 2000; Vaillant, 2003), but stable recovery is supposed to occur most frequently in the 40–49-year age group (Ojesjo et al., 2000). Some more recent population-based studies have suggested that recovery is more frequent or common than previously thought (Dawson et al., 2005), when mainly data from treatment populations have been considered. On the other hand, additional evidence of the stability of the alcohol dependence diagnosis, particularly in its more severe forms, has also emerged (Culverhouse et al., 2005).
An alcohol-induced depressive disorder lowers the probability of remission in alcohol and other substance dependence (Hasin et al., 2002). At symptom level, insomnia has recently been reported to associate with persistence of active alcohol dependence as opposed to a remitted state (Crum et al., 2004). The comorbidity of alcohol use with other mental disorders is supposed to complicate the treatment and worsen the course of any single disorder, and a weak correlation has been reported between the occurrence of a lifetime comorbid disorder and the persistence of an alcohol use disorder (Kessler et al., 1997; Randall et al., 2001; Schade et al., 2005). A recent 120 day follow-up study reported that baseline anxiety disorders predicted relapsing to drinking among alcohol-dependent subjects (Kushner et al., 2005). Panic disorder may share genetic risk factors with alcohol dependence, whereas social phobia may not (Merikangas et al., 1998). The onset of social phobia seems to precede the onset of alcohol dependence (Merikangas et al., 1998; Crum and Pratt, 2001). Despite emerging evidence of the complicating role of anxiety disorders in the course of alcohol dependence, population-level data on their comorbidity and remission rate are still meagre (Randall et al., 2001; Schade et al., 2005).
In the multidisciplinary Health 2000 project we aimed to investigate in a representative adult (30 years and over) sample (N = 6005) the characteristics of active and remitted alcohol dependence. Differences in sociodemographic characteristics, psychopathology, and service use between active and remitted alcohol dependence were examined to gain insight into possible factors influencing risk, severity, and recovery in alcohol dependence.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The Health 2000 Study was a multidisciplinary epidemiological survey in mainland Finland involving a regionally stratified sampling frame comprised of adults aged 30 years and over (N = 8028). The study was carried out in 2000–2001 and coordinated by the National Public Health Institute (KTL/NHPI). Data were collected via home (N = 6986) or telephone (N = 454) interviews and self-report questionnaires, followed by a clinical examination that included a structured mental health interview (M-CIDI). Structured BDI- and GHQ-12 questionnaires were used to obtain symptom measures for depressive mood and current psychic distress. These well-established instruments are commonly used to estimate the current psychic state, particularly in depressive and anxiety disorders (Steer et al., 1986
; Goldberg et al., 1997). The sampling and weighing procedure was designed to obtain a nationally representative sample of subjects from the general population, aged 30 years and over. Project details and methodology have been published earlier (Aromaa and Koskinen, 2004; Pirkola et al., 2005b).
The M-CIDI interview
The computer-aided mental health interview was performed at the end of a comprehensive health examination. The interview was designed to determine, among other things, the 12-month prevalence of major depressive episodes and disorder, dysthymia, general anxiety disorder, panic disorder with or without agoraphobia, agoraphobia, social phobia, and alcohol abuse and dependence. The subjects were also asked to estimate the age of first onset and the most recent timing of any of the symptoms of DSM-IV alcohol dependence. The total number of reliably performed mental health interviews was 6005, amounting to 75% of the original sample (8028). Compared to participants in the CIDI interview, those who only attended the home interview were found to differ by somewhat higher scores in BDI and GHQ symptom measures, by slightly older age, more frequent single marital status, and lower education. This has been reported and discussed earlier (Pirkola et al., 2005a, b). The M-CIDI offers a separate estimate on the fulfilment of alcohol abuse diagnosis, when excluding the diagnostic hierarchy rules. We controlled for the severity of alcohol dependence between remitted and active subjects, by analysing the prevalence of independent lifetime alcohol abuse.
Mental disorders and their comorbidity
The DSM-IV diagnoses found were grouped into categories of depressive-, anxiety- and alcohol-use disorders. The depressive disorders category included diagnoses of major depressive disorder or dysthymia during the past 12 months. Anxiety disorders included diagnoses of panic disorder (with or without agoraphobia), generalized anxiety disorder, social phobia, and agoraphobia (without panic disorder). Subjects with alcohol dependence were those having ever fulfilled within the same time period the diagnostic criteria of alcohol dependence. A separate estimate was made of whether those criteria had also been fulfilled within the past 12 months. If they had not, and a lifetime alcohol dependence diagnosis had been given, the subject was determined as being currently in remission from alcohol dependence. Comorbidity was defined as having suffered from disorders in more than one category within the previous 12 months.
Sociodemographic factors
Basic sociodemographic data—age, sex, marital status, and current employment status—were collected in the home interview. Persons living together were classified as cohabitants irrespective of their official marital status. Employment status was classified according to whether the subject was currently (i) full- or part-time employed, (ii) unemployed or laid off, (iii) retired, or (iv) other. Level of education was classified by years of education grouped into three categories: primary, secondary, and higher.
Use of services
In the initial home interview, the subjects were asked if a doctor had ever found them to suffer from a psychic or mental health-related illness, and whether this had been a substance use problem. The use of services for mental health-related problems within the previous 12 months was also evaluated. In the questionnaire given thereafter, the respondents were asked about use of formal services for any problems due to alcohol use within the previous 12 months. These questions were structured and performed as a comprehensive list for 11 different service providers. The broadest category was ‘use of any health or social care services due to problems with alcohol’. Use of e.g. primary health care, mental health outpatient care, psychiatric care or other hospital and occupational health care, was also queried. Specific alcohol-related services included A-clinic network and rehabilitation inpatient units. In addition, there were a few questions about lifetime involvement with certain health promotion activity groups, including whether they had ever attended an Alcoholic Anonymous (AA) meeting.
Smoking and alcohol use
Subjects were considered smokers if they reported in the initial home interview current daily smoking of cigarettes, cigars, or a pipe and having smoked at least a hundred times during their lifetime. In the diagnostic CIDI-interview, they were asked the age at which the first ever drink was consumed. In addition, whether or not the subject currently used alcohol, and the pattern of use, were evaluated in a first-phase questionnaire.
Childhood environmental factors
The questionnaires given to the subjects during the initial home interview contained a series of 11 questions about childhood environment. These covered parental alcohol use and mental health problems, familial discord and divorce, personal and parental serious physical illness, and being bullied at school (Pirkola et al., 2005a).
Statistical methods
In statistical analysis diagnostic categories and their correlates were examined by basic bivariate analyses, applying the t-test and the chi-square-test. Values of P < 0.05 were considered statistically significant. The odds ratios for factors differentiating between active and remitted alcohol dependence were derived from logistic regression analyses, adjusting for age and sex. Poststratification weights were used in the analyses to reduce the bias due to non-response and to correct for the oversampling (2:1) in the age group of 80 and over (Pirkola et al., 2005b). When analysing the small subpopulation of alcohol-dependent subjects (n = 458) and no regional analyses were made, the clustered sampling design was ignored and simple random sampling was assumed instead. The STATA (version 8.0) and SPSS (version 12.0.2) statistical packages were used for the analyses.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The overall lifetime prevalence of alcohol dependence was 7.9%. When weighed for age- and non-response -bias, alcohol dependence in the previous 12 months was diagnosed among 3.9%, and a remitted state (in terms of diagnostic criteria not being met within the previous year) was found in 4.1% of the subjects. Regardless of current status, the majority of alcohol-dependent subjects were males, and remitted subjects were slightly older than those actively dependent (47.5 vs 45.4 years, t = 2.2, P < 0.05). Remitted subjects were more often married than the actively dependent (51.0% vs 43.0%), and less often single (11.6% vs 20.7,
2 = 9.62, df = 4, P < 0.05). They were also more often retired (23.7% vs 13.0%) and less often employed (56.2% vs 63.0%) or unemployed (14.9% vs 20.2%, 2 = 10.96, df = 3, P < 0.05).
Social phobia (6.0% vs 0.8%, 2 = 9.95, df = 1, P < 0.01) and dysthymia (8.0% vs 3.2%, 2 = 5.24, df = 1, P < 0.05) were significantly more common among the actively alcohol-dependent than the remitted subjects (Tables 1 and 2). When adjusted for age and sex in a logistic regression model these associations remained significant. High level of education and single marital status also remained significant.
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The use of separate, specific treatment facilities for substance use was relatively infrequently reported and failed to correlate with diagnostic alcohol use status. Actively dependent subjects had used health care or social services for alcohol problems within the previous year in 15.6% of cases, and mental health services in 16.8%. The respective proportions were 4.4 and 8.1% for remitted alcohol-dependent subjects (Table 1). On the basis of all sources of information (interview and questionnaire), any health or social care service use for either mental health or substance-related problems within the previous 12 months was reported for 25.3% of the actively dependent, and 12.8% of the remitted (df = 1,
2 = 12.4, P < 0.001). Comorbid depressive or anxiety disorders increased the likelihood of receiving currently services for either of these problems, among both the actively dependent and remitted subjects (Table 3).
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Of remitted alcohol-dependent subjects 71.1% reported using any alcohol currently. The mean age at the time of the first lifetime drink did not differ between active and remitted alcohol-dependent subjects, being 16 years for both groups, and neither did the age at diagnosis among those assessed by a doctor as alcohol-dependent (35.7 years among the currently dependent, vs 38.4 years among the remitted, t = –1.34, n.s.) nor the estimate via the CIDI-interview of the age of onset of alcohol dependence (27 years among both the actively dependent and the remitted). A separate lifetime alcohol abuse diagnosis was found among 40.8% of the currently dependent and 47.6% of the remitted subjects (df = 1,
2 = 2.05, n.s.) The mean ages of onset for the most common CIDI-diagnoses other than alcohol dependence were: 43 years for GAD, 41 years for dysthymia, 25 years for social phobia, 31 years for panic disorder with agoraphobia, and 28 years for panic disorder without agoraphobia. The mean age of onset of alcohol dependence was 26 years for those with a comorbid anxiety or depressive disorder vs 29 years for those without this comorbidity (t = 2.9, P < 0.005). Regarding recalled past events, none of the adverse childhood experiences, including parental alcohol use or mental health problems, associated with active or remitted alcohol dependence.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In our Finnish Health 2000 study we found that relatively few sociodemographic, clinical or childhood-related factors differentiated the remitted from the actively alcohol-dependent subjects in the adult general population. Comorbid depressive and anxiety disorders were diagnosed in at least a fifth of both actively and remitted alcohol-dependent subjects. Compared with the remitted state, single persons, those with high educational level, and those with social phobia and dysthymia were more common among the active alcohol dependence patients. The actively dependent were currently more likely than the remitted to be receiving treatment or using services for either mental health problems or substance use related problems, but even among them this extended only to a quarter. Overall, among the alcohol-dependent subjects, certain typically long-term comorbid psychiatric disorders predominately associate with the active, non-remitted state.
The diagnostic characteristics
The remitted subjects did suffer from major depressive disorder, panic disorder, and agoraphobia as often as the actively dependent. The fact that social phobia and dysthymia in particular associate specifically with active alcohol dependence may reflect their long-term and prevailing nature (as opposed to a short term episodic, remitting course). These disorders may be detrimental to recovery efforts in the long run, possibly due to a more severe course of psychopathology with both independent and common risk factors—both genetic and environmental—for both disorders. Continuous use of alcohol among the actively dependent may also partly be due to self-medication against the disturbing symptoms of social phobia or dysthymia. The relationship between social phobia and development of an alcohol use disorder has been studied and reported previously, and causality in both directions has been suggested to exist (Crum and Pratt, 2001; Zimmermann et al., 2003). On the other hand, active and frequent alcohol use most likely maintains the typical symptoms of dysthymia and social phobia. Regardless of the causality issue, it is evident from previous research that the comorbidity of anxiety disorders in particular is a challenge for the treatment management of alcohol dependence (Randall et al., 2001; Kushner et al., 2005; Schade et al., 2005).
In our study, social phobia and panic disorder had different roles in terms of their prevalence among the active and remitted alcohol-dependent. Although they generally share some of their acute symptoms, it may be that social phobia has a more disrupting course in the presence of comorbid alcohol dependence. On the other hand, as we cannot explore the causal links between these disorders, it is possible that remission from alcohol dependence relieves the symptoms of social phobia but not of panic disorder. Furthermore, if panic disorder and alcohol dependence share some genetic risk factors, as suggested (Merikangas et al., 1998), the prevalence of panic disorder is perhaps relatively less dependent on the current state of alcohol dependence.
Treatment services
Actively alcohol-dependent subjects do currently use more health services or social care services for their problems with alcohol use, but no specific treatment facility (including lifetime use of AA) seems to associate with or precipitate remission. Health service use for mental health problems was also the most common among actively dependent subjects. It is interesting that although both the actively dependent and remitted alcohol-dependent suffered from comorbid depressive and anxiety disorders at the same level overall; the actively dependent used services for mental health problems twice as often as the remitted (17% vs 8%). This may be due to seeking help for a variety of problems not necessarily of psychiatric origin, but partly generated by alcohol problems. On the other hand, service use does not seem to be very frequent overall, given the high prevalence of alcohol use disorders and other mental disorders, and comorbid mental disorders very much determine this. We suggest that this comorbid psychopathology is a major challenge in the development of treatment for alcohol dependence and an important factor in explaining the poor treatment effects reported in many studies (Cutler and Fishbain, 2005).
Other characteristics
Somewhat surprisingly there were few sociodemographic or other characteristics distinguishing remission from active alcohol dependence. Age seemed to play a smaller role than expected as the differences in mean age and the age distribution were quite modest. The remission rate from alcohol dependence has been reported to increase with age (Bland et al., 1997), but it was not possible to clearly observe this in our study setting. It is worth noting, however, that the fact that these remitted subjects had not been alcohol-dependent within the previous 12 months does not necessarily represent a stable recovery. Follow-up studies of alcoholism treatment show that most relapses occur during the first year after treatment, but even if the risk of relapse is smaller after the first 12 months, some risk remains, as described for instance in the work of Ojesjo et al. (2000). However, the idea of experiencing a rock-bottom type of situation before remission was not supported in our population, although in a bivariate setting retirement was relatively more common (24% vs 14%) among the remitted subjects, and disproportionate with their age distribution (only 9% older than 65 years). This would suggest that in many cases disability pension had been granted prior to remission.
Neither did a variety of adverse childhood environmental factors seem to play a role in remission of our subjects. In this setting it seems that in addition to single marital status and high educational level, certain comorbid psychiatric disorders, current alcohol use, current service use, and smoking are the major specific factors associating with active alcohol dependence in relation to a remitted state.
Methodological considerations
As for the limitations of the present study, the main methodological issues to be considered are the retrospective data collection and the cross-sectional design of the study. The cross-sectional design precludes any causal conclusions. The findings presented here are merely descriptive of the current situation and should be interpreted with caution.
The retrospective nature of the data might cause some unreliability in reporting past alcohol use. As some of the remitted subjects are reportedly current users of alcohol, caution is warranted in interpretation of their remitted state. On the other hand, it may be that past alcohol use, even when abundant, may be easier to report than current use. In this M-CIDI application, alcohol use and particularly its consequences were explored by first asking the past or lifetime estimates and secondly, by investigating whether the diagnostic criteria of alcohol dependence were currently fulfilled. This method may at least in some of the subjects be an acceptable way to collect this type of sensitive data.
Due to the age range of 30 years and older, the subjects with active alcohol dependence may in general have been affected for a longer period than if younger subjects, too, had been included. This age-frame may have acted towards a more obvious distinction between actively dependent and remitted subjects. If younger subjects had been included, the whole picture could have been somewhat more mixed and other identifiable subgroups might have emerged.
Despite a relatively good response rate (75%) in the final CIDI interview, it is worth noting that the population not attending the interview most likely included subjects with poorer psychosocial functioning and also those with more severe problems with alcohol. The reported characteristics regarding BDI- and GHQ-12 -scores, and education seem convergent with this (Pirkola et al., 2005a, b) and suggest that the findings do not represent the whole spectrum of alcohol use problems. The weighing adjustment made to reduce the bias due to non-response and to correct for the oversampling may offer some protection for this bias, but the actual characteristics of the alcohol-dependent subjects among the non-respondents could not be explored.
The fact that in case of the subpopulation of alcohol dependent subjects we decided not to account for the clustering of the sampling design, might underestimate the standard errors of the estimates. However, we find this a minor concern, as our aim was to study a relatively small subpopulation of active and remitted alcohol dependent subjects.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Among alcohol-dependent subjects, only comorbid social phobia, dysthymia, and to some extent general anxiety disorder, associate specifically with an active state of alcohol dependence, suggesting that they either are obstacles to remission from an active state, explaining why some alcohol-dependent individuals are unable or recover, or that their symptoms are maintained by excessive use of alcohol. Possibly related to the total comorbidity of common mental disorders, the actively alcohol-dependent used both substance use services and mental health services considerably more often than the remitted subjects, possibly due to needs generated by their alcohol problem.
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ACKNOWLEDGEMENTS |
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This study was supported by the Academy of Finland grant No. 203742 (the MERTTU Project)
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