Young adult predictors of alcohol dependence to age 53: a 44-year prospective cohort study of Danish men

AIMS

To examine if (1) there is a positive association between drinking volume in young men and life-time risk of alcohol dependence (AD) and (2) there are other associations between young adulthood factors and life-time risk of AD.

DESIGN

Prospective cohort study of sons of fathers with alcohol use disorder (AUD) and matched low-risk controls without paternal AUD. Setting and participants A total of 204 men, who were assessed at baseline in 1979 at age 19-20 years, were followed through record linkage with Danish registers and consecutive psychiatric interviews at the ages of 33, 43 and 53 years.

MEASUREMENTS

AD diagnoses were interview-based according to the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, or made by treating clinicians according to the International Classification of Diseases (ICD) revision 8 (ICD-8) until 1993 and revision 10 (ICD-10) from 1994.We estimated odds ratios (ORs) with 95% confidence intervals (CI) for the development of AD after adjustment for confounders including smoking, social status and paternal AUD.

FINDINGS

The following variables from the examination at age 19-20 independently predicted life-time AD: alcohol consumption > 21 beverages/week versus 0-21 [odds ratio (OR) = 2.46, 95% confidence interval (CI) = 1.22-4.97], police contact (OR = 2.60, 95% CI = 1.28-5.28) and institutionalization related to the individual (OR = 2.90, 95% CI = 1.39-6.02). Compared with < 1 beverages/week, the risk for AD did not increase significantly for drinking volume categories: 1-7, 8-14 or 15-21 beverages/week.

CONCLUSION

Independently of other risk factors in young adulthood, young Danish men's risk for life-time alcohol dependence appears to be predicted by a drinking volume at age 19-20 years exceeding 21 beverages per week.

Sex-Role Typing: A Methodological Note

Contemporary measures of sex-role affiliation, which emphasize the relative independence of masculine and feminine attributes, typically rely upon a median-split procedure to generate a four-fold typology, e.g., masculine, feminine, indeterminant, and androgynous types. Methodological problems created by this classification technique are illustrated for one combined male/female sample and three male samples given the PRF ANDRO. The number in each standardization sample was Combined, 772; Males, 386; Alcoholics, 123; Veterans of Foreign Wars, 73. Sex-role typing was markedly influenced by the sample from which median cutting scores were derived.

Change in psychiatric symptomatology after benfotiamine treatment in males is related to lifetime alcoholism severity

BACKGROUND

Severe alcoholism can be associated with significant nutritional and vitamin deficiency, especially vitamin B1 (thiamine) which is associated with neurological deficits impacting mood and cognition. Alcohol consumption was reduced among female but not male alcoholics after supplementation with the high potency thiamine analog benfotiamine (BF). We examined the relationship between lifetime alcoholism severity, psychiatric symptoms and response to BF among the alcohol dependent men from this cohort.

METHODS

Eighty-five adult men (mean age=48±8 years) meeting DSM-IV-TR criteria for a current alcohol use disorder who were abstinent <30days participated in a randomized, double-blind, placebo-controlled trial of 600mg BF vs placebo (PL) for 6 months. Psychometric testing included a derived Lifetime Alcoholism Severity Score (AS), Symptom Checklist 90R (SCL-90R), and the Barratt Impulsivity Scale (BIS) at baseline and at 6 months.

RESULTS

Baseline SCL-90-R scale scores for men with high alcoholism severity (AS≥24; N=46 HAS) were significantly greater than for men with low alcoholism severity (AS<24; N=39 LAS), but BIS scores did not differ. MANOVA modeling at follow-up (N=50 completed subjects) identified a significant treatment effect (F=2.5, df=10, p<0.03) and treatment×alcoholism severity level interaction (F=2.5, dfnum=10, dfden=30, p<0.03) indicating reduced SCL-90-R scores among BF treated, HAS males. Above normal plasma thiamine levels at follow-up predicted reduced depression scores in a BF-treated subset (F=3.2, p<0.09, N=26).

CONCLUSION

BF appears to reduce psychiatric distress and may facilitate recovery in severely affected males with a lifetime alcohol use disorder and should be considered for adjuvant therapy in alcohol rehabilitation.

TRIAL REGISTRATION

#NCT00680121 High Dose Vitamin B1 to Reduce Abusive Alcohol Use.

A preliminary case study of androgen receptor gene polymorphism association with impulsivity in women with alcoholism

Objective

The androgen receptor (AR) gene, located on the X chromosome, contains a common polymorphism involving cytosine–adenine–guanine (CAG) repeats, which impacts disease and could contribute to the unequal sex ratio in alcoholism. CAG repeats in the AR gene are known to correlate with impulsivity in males. We report the first preliminary study examining the association between the number of CAG repeats and measures of impulsivity in females with chronic alcoholism.

Methods

A total of 35 women and 85 men with chronic alcoholism were previously recruited for a nutritional clinical trial, and 26 well-characterized females (19 African–American and seven Caucasian) with alcoholism agreed to participate for genetic testing. Genomic deoxyribonucleic acid (DNA) was isolated from peripheral blood and CAG repeats determined by analyzing polymerase chain reaction (PCR)-amplified products, using the polymorphic AR gene assay. CAG repeat length was correlated with raw scores from the Barratt Impulsivity Scale, version 11 and the Alcoholism Severity Scale.

Results

CAG repeat lengths were significantly longer in Caucasian alcoholic women compared with African–Americans, and the average number of CAG repeats were significantly, positively correlated (P<0.05) with impulsivity scores. Women with average CAG repeat length (CAG_ave) ≥18, representing the upper quartile of the repeat range, showed significantly greater mean raw impulsivity scores. CAG repeat length appeared to have less effect in African–American compared with Caucasian women, possibly due to a shorter average repeat length.

Conclusion

We found an association between the number of CAG repeats and impulsivity in females with chronic alcoholism, specifically in women with CAG_ave ≥18, seen more commonly in Caucasian compared with African–American women.

X chromosome inactivation in women with alcoholism

BACKGROUND

All female mammals with 2 X chromosomes balance gene expression with males having only 1 X by inactivating one of their X chromosomes (X chromosome inactivation [XCI]). Analysis of XCI in females offers the opportunity to investigate both X-linked genetic factors and early embryonic development that may contribute to alcoholism. Increases in the prevalence of skewing of XCI in women with alcoholism could implicate biological risk factors.

METHODS

The pattern of XCI was examined in DNA isolated in blood from 44 adult women meeting DSM-IV criteria for an alcohol use disorder and 45 control women with no known history of alcohol abuse or dependence. XCI status was determined by analyzing digested and undigested polymerase chain reaction (PCR) products of the polymorphic androgen receptor (AR) gene located on the X chromosome. Subjects were categorized into 3 groups based upon the degree of XCI skewness: random (50:50 to 64:36%), moderately skewed (65:35 to 80:20%), and highly skewed (>80:20%).

RESULTS

XCI status from informative women with alcoholism was found to be random in 59% (n = 26), moderately skewed in 27% (n = 12), or highly skewed in 14% (n = 6). Control subjects showed 60, 29, and 11%, respectively. The distribution of skewed XCI observed among women with alcoholism did not differ statistically from that of control subjects (χ(2) test = 0.14, 2 df, p = 0.93).

CONCLUSIONS

Our data did not support an increase in XCI skewness among women with alcoholism or implicate early developmental events associated with embryonic cell loss or unequal (nonrandom) expression of X-linked gene(s) or defects in alcoholism among women.

Effects of premature birth on the risk for alcoholism appear to be greater in males than females

OBJECTIVE

A large Danish birth cohort was used to test the independent and joint effects of perinatal measures associated with premature birth as predictors of the development of alcoholism in male and female subjects.

METHOD

Subjects were born at the Copenhagen University Hospital between 1959 and 1961 (N = 9,125). A comprehensive series of measures was obtained for each of the 8,109 surviving and eligible infants before birth, during birth, shortly after birth, and at 1 year. The adult alcoholism outcome was defined as any ICD-10 F10 diagnosis (Mental and behavioral disorders due to alcohol use) or an equivalent ICD-8 diagnosis found in the Danish Psychiatric Central Research Register or the Municipal Alcohol Clinics of Copenhagen by 2007.

RESULTS

Multiple perinatal markers of premature birth independently predicted the development of an alcoholism diagnosis in male (n = 310) but not female (n = 138) subjects. Logistic regression modeling with a global prematurity score, adjusted for social status, maternal smoking, and gender, indicated a significant association of prematurity score for males (p < .02), but not females (p = .51), on the risk of developing an alcohol use disorder.

CONCLUSIONS

The results suggest that neurodevelopmental sequelae of premature birth are associated with gender-specific effects on the development of alcoholism in the male baby: small, premature, or growth-delayed male babies appear to be selectively vulnerable to alcoholic drinking years later. The findings implicate neurodevelopmental influences in alcoholism pathophysiology in males and suggest the possibility of distinct, gender-specific pathways in the etiology of severe problem drinking.

Minor versus major depression: a comparative clinical study

OBJECTIVE

To examine whether minor depression differs from major depression in clinically relevant ways.

METHOD

Structured interviews, Symptom Checklist-90-Revised (SCL-90-R) scores, and physicians' treatment recommendations were obtained systematically from 1,458 admissions to an outpatient teaching clinic during a 5-year period from 1981 to 1986. Of these, 1,002 (69%) satisfied inclusive DSM-III lifetime criteria for a major depressive episode. Of the 456 outpatients who did not formally satisfy criteria for a major depressive episode, 79 (17%) acknowledged significant depressive symptoms that caused major interference in their lives. These 79 outpatients were classified as suffering from minor depression.

RESULTS

No gender or other sociodemographic differences were found between the 2 outpatient groups except that the minor depression group had achieved a higher level of education. No differences were found for a family history of psychiatric illness among first-degree relatives, including a family history of depression. Ratings of childhood unhappiness/problems did not distinguish the 2 groups. The major depression group endorsed more lifetime depressive symptoms and met criteria for more co-occurring disorders, principally mania and the anxiety disorders. The group with major depression reported poorer psychosocial functioning when first seen and more past psychiatric treatment. The Symptom Checklist-90-Revised (SCL-90-R) profile was significantly elevated in both groups. The type of initial treatment recommended did not distinguish the major from minor depression groups.

CONCLUSIONS

Minor depression seems to represent the same illness as major depression but in a less severe form that, nevertheless, requires the attention of professional health care providers in both primary and specialized care settings.

The contribution of parental alcohol use disorders and other psychiatric illness to the risk of alcohol use disorders in the offspring

BACKGROUND

Few population-based studies have investigated associations between parental history of alcoholism and the risk of alcoholism in offspring. The aim was to investigate in a large cohort the risk of alcohol use disorders (AUD) in the offspring of parents with or without AUD and with or without hospitalization for other psychiatric disorder (OPD).

METHODS

Longitudinal birth cohort study included 7,177 men and women born in Copenhagen between October 1959 and December 1961. Cases of AUD were identified in 3 Danish health registers and cases of OPD in the Danish Psychiatric Central Register. Offspring registration with AUD was analyzed in relation to parental registration with AUD and OPD. Covariates were offspring gender and parental social status.

RESULTS

Both maternal and paternal registration with AUD significantly predicted offspring risk of AUD (odds ratios 1.96; 95% CI 1.42 to 2.71 and 1.99; 95% CI 1.54 to 2.68, respectively). The association between maternal, but not paternal, OPD and offspring AUD was also significant (odds ratios 1.46; 95% CI 1.15 to 1.86 and 1.26; 95% CI 0.95 to 1.66, respectively). Other predictors were male gender and parental social status. A significant interaction was observed between paternal AUD and offspring gender on offspring AUD, and stratified analyses showed particularly strong associations of both paternal and maternal AUD with offspring AUD in female cohort members.

CONCLUSIONS

Parental AUD was associated with an increased risk of offspring AUD independent of other significant predictors, such as gender, parental social status, and parental psychiatric hospitalization with other diagnoses. Furthermore, this association appeared to be stronger among female than male offspring. The results suggest that inherited factors related to alcoholism are at least as important in determining the risk of alcoholism among daughters as among sons.

Do premorbid predictors of alcohol dependence also predict the failure to recover from alcoholism?

OBJECTIVE

In a search for viable endophenotypes of alcoholism, this longitudinal study attempted to identify premorbid predictors of alcohol dependence that also predicted the course of alcoholism.

METHOD

The 202 male subjects who completed a 40-year follow-up were originally selected from a Danish birth cohort (N = 9,182). Two thirds of the subjects were high-risk biological sons of treated alcoholics. A large number of measures (361) were obtained at different periods before any subject had developed an alcohol-use disorder. At age 40, a psychiatrist provided mutually exclusive lifetime diagnoses of alcohol abuse or alcohol dependence that were characterized as currently active or currently in remission according to Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, course specifiers.

RESULTS

The majority of subjects with a diagnosis of alcohol abuse were in remission at age 40 compared with those with a diagnosis of alcohol dependence (88% vs. 58%). Treatment did not predict remission. Fourteen of the 18 predictors of remission that also predicted dependence were submitted to an exploratory factor analysis (varimax). Two premorbid dimensions were identified: cognitive efficiency and early behavioral dyscontrol in childhood. Both factors predicted the failure to remit (low cognitive efficiency and high behavioral dyscontrol) even when lifetime alcoholism severity was controlled.

CONCLUSIONS

This 4-decade study found a striking disconnect between measures that predicted alcohol dependence and measures that predicted remission from alcohol dependence. Reduced cognitive efficiency and increased behavioral dyscontrol may be basic to gaining a fuller understanding of the etiology of alcoholism.

Childhood ADHD and conduct disorder as independent predictors of male alcohol dependence at age 40

OBJECTIVE

The Danish Longitudinal Study on Alcoholism was designed to identify antecedent predictors of adult male alcoholism. The influence of premorbid behaviors consistent with childhood conduct disorder (CD) and attention-deficit/hyperactivity disorder (ADHD) on the development of alcohol misuse was examined.

METHOD

Subjects were selected from a Danish birth cohort (9,125), which included 223 sons of alcoholic fathers (high risk) and 106 matched sons of nonalcoholic fathers (low risk). These subjects have been studied systematically over the past 40 years. They were evaluated in their teens (n=238), later as adults at age 30 (n=241), and more recently at age 40 (n=202). At 19-year/20-year follow-ups, an ADHD scale was derived from teacher ratings and a CD scale was derived from a social worker interview. At 30-year and 40-year follow-ups, a psychiatrist used structured interviews and criteria from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, to quantify lifetime alcoholism severity and to diagnose alcohol-use disorder. Of the original subjects, 110 had complete data for the two childhood measures and the adult alcoholism outcomes.

RESULTS

In this smaller subsample, paternal risk did not predict adult alcohol dependence. Subjects who were above a median split on both the ADHD and the CD scales were more than six times more likely to develop alcohol dependence than subjects who scored below the median on both. Although the two childhood measures were correlated, a multiple regression showed that each independently predicted a measure of lifetime alcoholism severity.

CONCLUSIONS

ADHD comorbid with CD was the strongest predictor of later alcohol dependence.

Paternal alcoholism predicts the occurrence but not the remission of alcoholic drinking: a 40-year follow-up

OBJECTIVE

To test the effects of father's alcoholism on the development and remission from alcoholic drinking by age 40.

METHOD

Subjects were selected from a Danish birth cohort that included 223 sons of alcoholic fathers (high risk; HR) and 106 matched controls (low risk; LR). Clinical examinations were performed at age 40 (n = 202) by a psychiatrist using structured interviews and DSM-III-R diagnostic criteria.

RESULTS

HR subjects were significantly more likely than LR subjects to develop alcohol dependence (31% vs. 16%), but not alcohol abuse (17% vs. 15%). More subjects with alcohol abuse were in remission at age 40 than subjects with alcohol dependence. Risk did not predict remission from either alcohol abuse or alcohol dependence.

CONCLUSION

Familial influences may play a stronger role in the development of alcoholism than in the remission or recovery from alcoholism.

Indicators of mania in depressed outpatients: a retrospective analysis of data from the Kansas 1500 study

OBJECTIVE

Previous prospective studies have shown that unipolar depressed patients often switch to a manic episode. Some of these studies have reported that the conversion to bipolar disorder is predicted by an early onset of depression, a positive family history for mania, and psychotic symptoms. The present study examines the strength of the relationship between these 3 indicators, both alone and in combination, and the presence of mania in a large retrospective analysis.

METHOD

1458 consecutive admissions to a large, Midwestern university outpatient clinic between 1981 and 1986 were interviewed, and 1002 patients met DSM-III inclusive criteria for major depressive disorder. Of these, information about age at onset of depression, family history of mania, and psychotic symptoms was available on 744 outpatients. Two structured interviews were used to assess the 3 indicators.

RESULTS

In this large depressed outpatient sample, the incidence of lifetime mania was 27%. Each of the 3 indicators was significantly associated with the report of mania (p < .0001 for all 3 indicators). The rates of mania increased as the number of indicators increased. Psychotic symptoms were the strongest indicator, followed by a family history of mania and an early age at onset of depression.

CONCLUSION

Depressed patients with 1 or more of these 3 indicators should be monitored for the presence of bipolar disorder. Patients with 2 or more of these indicators are especially at risk to develop mania.

A theoretical argument for inherited thiamine insensitivity as one possible biological cause of familial alcoholism

Thiamine deficiency has been specifically linked to the development of Wernicke-Korsakoff syndrome (WK)--a degenerative brain disorder that is typically associated with alcoholic drinking. Alcoholism-related thiamine deficiency is a major cause of WK. However, an inherited abnormality in thiamine utilization has been identified in some WK patients that may predispose heavy drinkers to this severe neurological syndrome. Individuals who possess this variant require more thiamine throughout their lives to prevent them from experiencing thiamine deficiency. Recent prospective studies have implicated early childhood nutritional and environmental influences in the etiology of alcoholism in adults. These studies have suggested that developmental abnormalities involving brain white matter growth might precipitate the later development of alcoholism possibly by altering the emerging reward-related brain systems. Brain white matter growth is highly sensitive to nutritional deficiency (including thiamine deficiency) and oxidative injury, especially during the perinatal period. The proposed model of familial alcoholism hypothesizes that an inherited insensitivity to thiamine can precipitate brain abnormalities very early in life that will greatly increase the risk of developing alcoholism in adulthood. This paper offers a heuristic model of a possible mechanism by which both inherited and environmental factors related to thiamine utilization might coaggregate to cause alcoholism.

Neonatal vitamin K might reduce vulnerability to alcohol dependence in Danish men

OBJECTIVE

Levels of oxidative defenses and blood-clotting factors are normally reduced in newborns, increasing the risk of injury to developing brain structures around the time of birth. This early neonatal vulnerability corresponds to a timeframe in which the development of reward-related limbic structures is particularly active. Taking advantage of a serendipitous event in the history of treating newborns, we tested the hypothesis that vitamin K supplementation, administered to facilitate the synthesis of blood-clotting proteins within this critical timeframe, might also reduce the development of alcohol dependence later in life.

METHOD

Subjects were approximately full-term male infants, selected from a large Danish birth cohort. Two thirds of the original 330 subjects in this study were high-risk sons of alcoholic fathers; 241 of the total completed the 30-year follow-up. Of subjects reported on for this article (N = 238), 44 received vitamin K supplementation at birth; 161 were considered high risk, and 66 were categorized as having lower birth weight (<6 lbs). A comprehensive series of measures was obtained on each subject before, during and shortly after birth as well as at 1 year of age. The Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, diagnosis of alcohol dependence and a measure of lifetime problem drinking served as the 30-year outcome variables.

RESULTS

Vitamin K treatment, inherited risk and low birth weight each independently predicted alcohol dependence and problem drinking at age 30. Vitamin K treatment was associated with significantly lower rates of alcohol dependence and fewer symptoms of problem drinking.

CONCLUSIONS

Vitamin K treatment at birth might protect against the development of alcoholism in adults by reducing early postnatal hemorrhage and oxidative brain damage.

Developmental Differences in Childhood Motor Coordination Predict Adult Alcohol Dependence: Proposed Role for the Cerebellum in Alcoholism

BACKGROUND

The Danish Longitudinal Study of Alcoholism has identified a number of early biological indicators that predicted alcohol dependence 30 years later. In light of recent evidence linking deficits of the cerebellum to certain neuropsychiatric disorders often comorbid with alcoholism, we hypothesized that developmental deficits in the cerebellar vermis may also play a role in the initiation of adult alcohol dependence. The present study evaluated whether measures of motor development in the first year of life predict alcohol dependence three decades later.

METHODS

A total of 241 subjects of the original 330 infants who were entered into this study completed the 30-year follow-up (12 had died). The subjects were men who were drawn from a large birth cohort born in Copenhagen, Denmark, from 1959 to 1961. A comprehensive series of measures were obtained on each subject before, during, and shortly after birth as well as at 1 year of age. Muscle tone at birth and day 5 as well as 1-year measures of motor coordination--age to sitting, standing, and walking--were examined. A DSM-III-R diagnosis of alcohol dependence and a measure of lifetime problem drinking served as the 30-year outcome variables.

RESULTS

Several measures of childhood motor development significantly predicted alcohol dependence at 30 years of age. These included deficits in muscle tone 5 days after birth, delays in the age to sitting, and delays in the age to walking.

CONCLUSIONS

Relationships found between adult alcoholism and early delays in motor development offer support for the theory that cerebellar deficits may play a causal role in the addiction process.

Development of scales to screen for eight common psychiatric disorders

The present study was designed to create a group of scales from the items on the Symptom Checklist 90 (SCL-90) to identify common psychiatric diagnoses. Subjects were 1457 adult psychiatric outpatients who completed the Symptom Checklist-90 and a structured diagnostic interview at the time of their initial evaluation. A combination of rational and empirical test construction methods was used to create the SCL-90 Diagnostic Scales, item sets that identify eight common psychiatric conditions: major depression, bipolar disorder, schizophrenia, antisocial personality disorder, somatization disorder, obsessive-compulsive disorder, panic disorder, and agoraphobia. These specially constructed scales were found to possess good internal reliability. These scales were also shown to differentiate patients positive for each of the eight psychiatric disorders from other psychiatric patients who did not have that disorder. Sensitivities and specificities are reported for each item set. In addition to their utility at the time of initial assessment as an aid in identifying diagnosis, the SCL-90 Diagnostic Scales may have other potential uses, such as in monitoring the symptom course of the patient's disorder or disorders over time.

Prediction of mortality at age 40 in Danish males at high and low risk for alcoholism

OBJECTIVE

This prospective high-risk study examined the influence of father's alcoholism and other archival-generated measures on premature death.

METHOD

Sons of alcoholic fathers (n = 223) and sons of non-alcoholic fathers (n = 106) have been studied from birth to age 40. Archival predictors of premature death included father's alcoholism, childhood developmental data, and diagnostic information obtained from the Psychiatric Register and alcoholism clinics.

RESULTS

By age 40, 21 of the 329 subjects had died (6.4%), a rate that is more than two times greater than expected. Sons of alcoholic fathers were not more likely to die by age 40. Premature death was associated with physical immaturity at 1-year of age and psychiatric/alcoholism treatment. No significant interactions were found between risk and archival measures.

CONCLUSION

Genetic vulnerability did not independently predict death at age 40. Death was associated with developmental immaturities and treatment for a psychiatric and/or substance abuse problem.

Risk factors that predicted problem drinking in Danish men at age thirty

OBJECTIVE

The Danish Longitudinal Study of Alcoholism utilized a prospective, high-risk research paradigm to identify putative markers of adult male alcoholism from a comprehensive database that began with the birth of the subject and extended over three decades. This article focuses on measures antedating abusive drinking that predicted lifetime alcohol abuse/dependence at age 30 years.

METHOD

The original 330 subjects of this study were drawn from a large Danish birth cohort (N = 9,125) born between 1959 and 1961. The sample included 223 sons of treated alcoholic fathers (high-risk group) and 107 matched sons whose biological fathers had no record of treatment for alcoholism (low-risk group). This sample has been thoroughly investigated with a variety of methods representing multiple domains that included perinatal records, pediatric records, school records, teacher ratings, school physician records and a series of structured interviews and psychometric tests at ages 19-20 and 30 years. The present analysis focuses on the degree to which premorbid differences between the high- and low-risk groups later predicted lifetime drinking problems at age 30 (n = 241).

RESULTS

As expected lifetime alcohol abuse/dependence by age 30 was reported significantly more often in the high-risk group. Of the 394 premorbid variables tested, 68 were found to distinguish the high- from the low-risk group before any subjects had developed a drinking problem. Of these 68 variables, 28 (41%) were also associated with DSM-III-R alcohol abuse/dependence at age 30. These 28 putative markers were reduced to 12 that were entered into a multiple regression analysis to search for the most powerful unique predictors of alcoholism. Four of the 28 putative markers were independently associated with problem drinking at age 30: low birth weight, number of life crises in childhood, ratings of childhood unhappiness and antisocial personality disorder. The regression model accounted for 46% of the drinking outcome variance. A father's alcoholism by itself no longer independently contributed to the prediction of his son's drinking and with one exception, did not systematically interact with the putative markers to facilitate the prediction of alcohol dependence at age 30.

CONCLUSIONS

Risk itself. which significantly predicted problem drinking at age 30, was not uniquely associated with the development of alcoholism in adulthood. These findings, rather, provide broad support for the biopsychosocial model of alcoholism, especially for those models that emphasize the cumulative influence over time of internal and external variables in biologically vulnerable individuals.

Comparison of desipramine or carbamazepine to placebo for crack cocaine-dependent patients

The authors compared the effects of desipramine or carbamazepine to placebo in an intensive outpatient program for cocaine abuse. Subjects recruited from an urban drug treatment program were randomly assigned to a double-blind, placebo-controlled, eight-week trial of desipramine, carbamazepine, or placebo. Patient ratings, urine drug screens, and blood samples were obtained weekly. Using survival analysis, the three groups did not differ in time to drop out of treatment. While subjects improved over time on all self-ratings related to cocaine use, mood, and craving, only two items related to mood were significantly different over time as a function of treatment group. Subjects in the two treated groups reported significantly more improvement on self-ratings of depression and irritability. No treatment differences were noted for sustained abstinence or for proportion of positive urine drug screens. Desipramine subjects who attained a minimum blood level were retained in treatment significantly longer than placebo or other non-compliant treatment groups. This finding supports previous reports of a possible role for desipramine in cocaine abuse treatment.

Methadone therapy for opioid dependence

The 1999 Federal regulations extend the treatment options of methadone-maintained opioid-dependent patients from specialized clinics to office-based opioid therapy (OBOT). OBOT allows primary care physicians to coordinate methadone therapy in this group with ongoing medical care. This patient group tends to be poorly understood and underserved. Methadone maintenance therapy is the most widely known and well-researched treatment for opioid dependency. Goals of therapy are to prevent abstinence syndrome, reduce narcotic cravings and block the euphoric effects of illicit opioid use. In the first phase of methadone treatment, appropriately selected patients are tapered to adequate steady-state dosing. Once they are stabilized on a satisfactory dosage, it is often possible to address their other chronic medical and psychiatric conditions. The maintenance phase can be used as a long-term therapy until the patient demonstrates the qualities required for successful detoxification. Patients who abuse narcotics have an increased risk for human immunodeficiency virus infection, hepatitis, tuberculosis and other conditions contributing to increased morbidity and mortality. Short- or long-term pain management problems and surgical needs are also common concerns in opioid-dependent patients and are generally treatable in conjunction with methadone maintenance.

Mortality in male alcoholics after ten to fourteen years

OBJECTIVE

Alcoholics frequently die prematurely. The purpose of this study was to determine: (1) whether subjects in a sample of 360 male alcoholics, followed over a period of 10-14 years, died prematurely: (2) if so, from what causes; and (3) whether such deaths are predictable from characteristics present at initial assessment.

METHOD

Subjects were male veterans (N = 360) with a diagnosis of alcoholism admitted to an inpatient substance abuse treatment program at the Kansas City Veterans Affairs (VA) Medical Center during 1980-1984 who consented to participate in intake evaluations and subsequent follow-ups at 1 year and 10-14 years later. Of the 357 (99.2%) men located at the 10-14 year follow-up, 96 (26.6%) were confirmed as deceased, 255 survivors agreed to be reassessed and 6 subjects refused reassessment. Information regarding cause of death was obtained from death certificates, VA records and other sources.

RESULTS

At intake, the subsequently deceased men were older, had less education, lower psychosocial functioning, more medical problems and greater psychiatric severity. Their overall death rate was 2.5 times greater than that of a reference group of men. Men in the 35-44 year age group were 5.5 times as likely to die. A statistical model utilizing measures of alcohol dependence to predict mortality from intake to 10-14 year follow-up indicated that alcoholics who limited drinking were half as likely to die whereas those who engaged in morning drinking were 2.5 times more likely to die.

CONCLUSIONS

Alcoholic men, especially those in the group aged 35 to 44 years, have a significantly higher risk of premature death than a reference group of men. Men who engaged in morning drinking and could not limit drinking appeared to be at higher risk of mortality 10 years later.

Comorbid psychiatric diagnosis and long-term drinking outcome

This longitudinal study of alcoholics investigated which psychiatric comorbidities among alcoholics would predict very long-term drinking outcome. Previous research has yielded inconsistent findings. We hypothesized that antisocial personality characteristics alone among psychiatric comorbidities would show an association with poorer drinking outcome. The use of multiple measures of psychopathology, a relatively large sample size, and an absence of systematic treatment matching to particular patient groups were all aspects of the current study which allowed for a comprehensive examination of this issue. The study used single and multivariate correlational analyses. The setting was an inpatient Veterans Administration alcohol dependence treatment unit and follow-up clinic. Participants were 255 adult male veterans diagnosed with alcohol dependence. The predictors were the Symptom Checklist 90 (SCL), Minnesota Multiphasic Personality Inventory (MMPI), and Psychiatric Diagnostic Interview (PDI). The outcome measure was the Clinician Rating of Drinking Scale (CRDS). The study showed that antisocial personality characteristics alone were consistently associated with a worse long-term drinking outcome. However, despite the consistent presence of a statistical association between antisocial personality characteristics and a poorer long-term drinking outcome, the small size of the relationship is a very important issue which is discussed in detail.

Breast-feeding and alcoholism: the Trotter hypothesis

OBJECTIVE

The authors' goal was to determine whether early termination of breast-feeding contributes to later alcohol dependence, as proposed more than 200 years ago by the British physician Thomas Trotter.

METHOD

In 1959-1961, a multiple-specialty group of physicians studied 9, 182 consecutive deliveries in a Danish hospital, obtaining data about prepartum and postpartum variables. The present study concentrates on perinatal variables obtained from 200 of the original babies who participated in a 30-year high-risk follow-up study of the antecedents of alcoholism.

RESULTS

Of the 27 men who were diagnosed as alcohol dependent at age 30, 13 (48%) came from the group weaned from the breast before the age of 3 weeks; only 33 (19%) of the 173 non-alcohol-dependent subjects came from the early weaning group. When challenged by other perinatal variables in a multiple regression analysis, early weaning significantly contributed to the prediction of the severity of alcoholism at age 30.

CONCLUSIONS

The data support the hypothesis that early weaning may be associated with a greater risk of alcohol dependence later in life.

The comparative validity of eleven alcoholism typologies

OBJECTIVE

This study directly compared the clinical validity of 11 empirically defined alcoholism typologies to determine whether some typologies are clinically more valid than others.

METHOD

A sample of 360 hospitalized alcoholic men were extensively evaluated at entry into the study and again 1 year later. Twenty-three measures of clinical validity were employed; 15 were postdictive and 8 were predictive. Postdictive retrospective measures obtained at entry into the study included family history, age of onset and lifetime course characteristics associated with alcoholism severity, general psychopathology and psychosocial functioning. Predictive outcome measures drawn from information obtained during the 1-year follow-up included: abstinence, alcoholism severity and clinician ratings of outcome. The measures were subjected to various statistical analyses, including factor analysis.

RESULTS

We found that all of the alcoholism typologies met at least 7 of the 23 a priori measures of clinical validity. The correlations between these conceptually and methodologically disparate typologies were often striking. Exploratory factor analysis, which explained 35% of the variance, suggested three possible underlying dimensions to account for the overlap among typologies: (1) age and its correlates, including age-of-alcoholism onset; (2) "pure" alcoholism versus psychiatrically heterogeneous alcoholism that encompassed antisocial personality disorder; and (3) current severity of psychiatric distress, impairment and dysfunction.

CONCLUSIONS

No single method of subtyping alcoholics clearly emerged as superior. All demonstrated some degree of predictive and postdictive clinical validity. Most methods of subtyping correlated positively with each other at moderate, but typically significant, levels.

Prediction of drinking outcomes for male alcoholics after 10 to 14 years

This study reports on the long-term outcomes of 360 men who were hospitalized for alcoholism during 1980 to 1984 and followed at 12 months and again 10 to 14 years later. At the 10/14-year follow-up, 96 (26.7%) men were confirmed as deceased; 255 (70.8%) men participated in the assessment/interview battery completed during baseline hospitalization. The battery consisted of psychosocial, alcohol-related, and psychiatric measures. Two distinct but highly correlated outcome measures were selected: a clinical rating scale and a factor score. Overall, predictors from baseline and 12-month follow-up included age at intake hospitalization, alcoholism severity, social stability, drinking days, and antisocial personality disorder. Approximately 37% of the assessed survivors were either totally abstinent or drinking nonabusively throughout the 10/14-year follow-up, whereas another 37% continued to drink abusively. Men who abstained or reduced alcohol intake reported better physical health at follow-up than those who continued to drink. Although our findings did not directly link alcoholism to death, they strongly indicate that chronic alcohol abuse may lead to premature death.

Pharmacological treatment for antisocial personality disorder alcoholics: a preliminary study

A short time ago, we reported that a subgroup of hospitalized alcoholic men with comorbid antisocial personality disorder (ASP) seemed to benefit significantly from antidepressant medication at the end of a 6-month period in a double-blind, random assignment, placebo-controlled study. In a reanalysis of those data, we divided the ASP alcoholic group (n = 29) into those who did (n = 15) and who did not (n = 14) also satisfy DSM-III-R criteria for an additional current mood and/or anxiety disorder and then compared the 6-month outcomes of these two smaller subgroups. Despite the small ns, the results for most drinking outcome measures indicated: (1) that ASP alcoholics with a current mood/anxiety disorder improved significantly more with pharmacological treatment, relative to placebo; and (2) that ASP alcoholics with no current mood/anxiety disorder failed to respond differentially to pharmacological treatment over the 6-month period. These findings suggest a possibly useful and inexpensive approach to the long-term management of a very difficult-to-treat subgroup of men substance abusers.

The electroencephalogram after alcohol administration in high-risk men and the development of alcohol use disorders 10 years later

BACKGROUND

In 1979 through 1980, electroencephalographic (EEG) responses to an alcohol challenge in 19 year-old sons of alcoholics as well as in sons of nonalcoholic control subjects were examined. The familial risk status of the subjects and greater EEG sensitivity to alcohol were hypothesized to predict the development of alcoholism 10 years later.

METHODS

In 1990 through 1992, diagnostic interviews were completed to ascertain alcohol and other substance use disorders in these subjects and to update their family history.

RESULTS

Updated family history of alcoholism predicted the development of substance dependence. Density of alcoholic relatives (the number of alcoholic relatives divided by the number of known relatives) was positively related to the severity of alcohol use disorders in the probands. Contrary to expectation, a greater EEG response at age 19 years was not related to the later development of alcohol dependence. Instead, the opposite was observed: a smaller EEG alpha frequency response to alcohol at age 19 years was related to the development of alcohol dependence and high quantity and frequency of alcohol consumption 10 years later.

CONCLUSIONS

Lower EEG response to a small dose of alcohol may be associated with the later development of alcohol dependence. This result is based on a small number of subjects and should be interpreted with caution. Although this result is opposite to our 1980 hypothesis, it is consistent with much of the recent literature.

A double-blind, placebo-controlled study of nortriptyline and bromocriptine in male alcoholics subtyped by comorbid psychiatric disorders

This double-blind, placebo-controlled, 6-month follow-up treatment study investigated the efficacy of bromocriptine and nortriptyline in attenuating drinking behavior and psychiatric symptoms in 216 male alcoholic patients subtyped by comorbid psychiatric disorder(s). Three well-defined subtypes were examined: alcoholism only, alcoholism + affective/anxiety disorder, and alcoholism + antisocial personality disorder. It was hypothesized that both medications would relieve negative affective symptoms associated with alcohol use and would be particularly effective for the affective/anxiety subgroup. Contrary to our predictions, the only significant effects found were with the antisocial personality disorder patients who were receiving nortriptyline. One interpretation of the results was that nortriptyline may have reduced impulsive drinking in the antisocial personality disorder subgroup by actions on serotonergic neurotransmission.

Psychometric characteristics of the trait version of the Depression Adjective Check Lists (DACL) in adult psychiatric outpatients

Psychometric characteristics of the trait version of Set 2 (E, F, G) of the Depression Adjective Check Lists (DACL) were studied in a sample of 177 consecutive admissions to a university medical center clinic of adult psychiatric outpatients (60 males, 117 females). The SCL-90-R and the Psychiatric Diagnostic Interview also were administered. The trait DACL was shown to have high internal consistency (.90 to .92) and alternate form reliability (.86 to .92) and good concurrent (.76) and discriminant validity. The DACL (E, F, G) was able to differentiate between those with or without the presence of a Major Depression. There was a significant correlation between DACL E and levels of distress and psychopathology. In addition, the magnitude of DACL score significantly differentiated psychiatric diagnostic groups.

Co-morbidity of lifetime psychiatric disorder among male alcoholic patients

The lifetime co-morbidity of major psychiatric disorders among male alcoholics was examined with the structured Psychiatric Diagnostic Interview (PDI), which was administered to 928 patients undergoing alcoholism treatment at six Veterans Administration Medical Centers. Thirty-eight percent were positive for alcoholism only; 62% fulfilled inclusive lifetime diagnostic criteria for at least one other additional psychiatric syndrome. Thirty percent satisfied criteria for one additional syndrome; 16% for two additional syndromes; 12% for three; and 4% for four or more disorders in addition to alcoholism. Depression and antisocial personality were the most frequently identified co-occurring syndromes (36% and 24%, respectively) followed by drug abuse and mania (17% each). The additional psychiatric syndromes in this sample were clearly not randomly distributed; instead, certain disorders tended to cluster together such as: drug abuse and antisocial personality; mania and depression; depression and anxiety disorder; and schizophrenia and affective disorder. Implications for classification and treatment are discussed.

Outcomes of co-morbid alcoholic men: a 1-year follow-up

In this prospective, 1-year study, 360 males admitted to an inpatient alcoholism treatment program were administered a DSM-III compatible structured interview and subtyped by co-occurring psychiatric disorder. Forty percent satisfied diagnostic criteria for alcohol dependence while 27% met criteria for alcohol dependence and one additional psychiatric syndrome. The dually diagnosed patients were divided into: alcohol dependence plus drug abuse, alcohol dependence plus antisocial personality and alcohol dependence plus depression. These subtypes were compared on multiple dimensions at intake and at 1-year follow-up. At follow-up, all groups showed significant improvement in drinking and psychosocial functioning. The results suggest that subtyping alcoholics by co-morbid psychiatric disorders may be a good postdictor of clinical history, but a poor predictor of drinking outcome.

A comparison of familial and nonfamilial male alcoholic patients without a coexisting psychiatric disorder

Both family history of alcoholism and the presence of additional psychiatric disorder in male alcoholic patients are associated with an earlier onset of problem drinking, greater alcoholism severity and poorer clinical outcomes. To assess the relative contribution of family history alone, a sample of 212 male alcoholics not positive for any other psychiatric disorder was selected and divided into those with a family history of alcoholism (FH+) or no family history of alcoholism (FH-) among first degree relatives. Although FH+ alcoholics reported a younger age of onset of problem drinking and greater severity of some alcohol-related sequelae, the differences were not as extensive or pronounced as those found in a previous study of a sample of psychiatrically heterogeneous patients (Penick et al., 1987). A bi-dimensional typology of alcoholism incorporating both additional psychiatric diagnoses and a positive family history of alcoholism is suggested.

Examination of Cloninger's type I and type II alcoholism with a sample of men alcoholics in treatment

Cloninger's clinical method of classifying alcoholics into two groups (Types I and II) was examined with data obtained from 360 VA hospitalized male alcoholic patients. For operational criteria, the Cloninger clinical method of subtyping alcoholics employs age-of-onset of problem drinking and symptom-clusters supposedly associated with each subtype. Marked overlap was found between the symptom-clusters used to define the two subtypes. Ninety-one percent of the entire sample satisfied criteria for both symptom-clusters. Dividing the sample by early-onset (Type II, less than or equal to 25 years) and late-onset (Type I, greater than 26 years) alcoholism did not substantially reduce the overlap between symptom-clusters; i.e., 96% of the early-onset and 83% of the late-onset subgroups were positive for both symptom-clusters. Only 21 men (6%) could be classified when both age-of-onset and the type-appropriate symptom-cluster were used to separate patients. In hospital settings, at least, these findings suggest that the two-group clinical alcoholism typology proposed by Cloninger basically reflects the age-of-onset of problem drinking.

Subtyping male alcoholics by family history of alcohol abuse and co-occurring psychiatric disorder: a bi-dimensional model

Six studies of 568 alcoholics in treatment are summarized to illustrate the interactive effects of familial alcoholism, other forms of family psychopathology and the lifetime prevalence of additional psychiatric disorder on the onset and course of male alcoholism. A family history of alcoholism as well as additional co-occurring psychiatric syndromes were associated with (1) earlier onsets of problem drinking, (2) a more virulent course and (3) greater heterogeneity of psychopathology among first degree relatives. A bi-dimensional method of classifying male alcoholics is proposed which combines a family history of abusive drinking and the presence or absence of co-morbid psychiatric disorders. Implications for the clinical researcher and practitioner are briefly discussed.

Alcoholics' attitudes toward and experiences with disulfiram

We studied 345 alcoholic inpatients utilizing a 43-item questionnaire designed to assess these patients' attitudes toward and experiences with disulfiram. A surprisingly high number of patients who had received disulfiram drank ethanol while taking or within 1 week of stopping disulfiram and experienced a disulfiram ethanol reaction. This finding and others derived from the questionnaire are reported, and the potential implications of the findings are discussed.

The stability of coexisting psychiatric syndromes in alcoholic men after one year

Alcoholic men (N = 241) were administered a criterion-referenced, structured, DSM-III compatible, diagnostic interview while hospitalized and again 1 year later as outpatients. This interview independently evaluates the lifetime prevalence of 15 major psychiatric disorders. In addition to alcoholism, the most frequently occurring coexisting disorders were depression, antisocial personality and drug abuse. After 1 year, the number of positive syndromes declined slightly (chi = 2.0 to 1.8). However, the absolute and relative number of additional psychiatric syndromes remained stable over 1 year for the entire sample. Across individuals, the overall rates of agreement for the 15 syndromes ranged from a high of 100% to a low of 85%. Similarly, the agreement for the current and lifetime diagnoses ranged from 86 to 99%. These data indicate that a substantial portion of male alcoholics experience symptoms that are common to other psychiatric disorders. They also suggest that the endorsement of multiple psychiatric symptoms is not due simply to the acute emotional and physical distress that often accompanies a recent hospitalization for alcoholism treatment. Instead, for many male alcoholics, the symptom patterns appear to reflect additional psychiatric disorders that are stable over time and a potential target of treatment.

A comparative study of familial alcoholism

In a large multicenter study of 568 male alcoholics, structured interviews were used to compare the clinical characteristics of patients with a positive (65%) or negative (35%) family history of abusive drinking among first degree relatives. Alcoholics with a positive family history were found to have: an earlier onset of alcoholism, greater alcoholic severity, more medical and legal problems, a broader range of treatments, an increased lifetime prevalence of additional psychiatric disorders and a greater diversity of psychiatric disturbance among biological relatives. The degree of psychiatric heterogeneity in the patients roughly corresponded to the degree of psychiatric heterogeneity in their families. Assortative mating was proposed as a possible mechanism to account for clinical differences between the familial and nonfamilial alcoholic.

Primary and secondary depression in alcoholic men: an important distinction?

The primary-secondary depression distinction was investigated in male alcoholic patients from five Veterans Administration Medical Centers. The Psychiatric Diagnostic Interview, a DSM-III-compatible, criterion-referenced, structured interview, was administered to 565 patients admitted to the Alcoholism and Drug Treatment Units. Seventy-eight patients (13.8%) who exhibited only alcoholism and depression were divided into three subgroups based on the temporal onset of depression relative to the onset of alcoholism. Although few statistical differences were found, observed trends suggested more impairment in alcoholic patients with primary depression than in those with concurrent or secondary depression. The findings indicate that the primary-secondary depression distinction may have important clinical relevance and should be made whenever possible.

The dropout in alcoholism research: a brief report

Compared to 148 alcoholic men who were successfully followed up after 1 year in a controlled treatment evaluation study, the 18 treatment dropouts reported somewhat less alcohol impairment due to drinking and lower scores on measures of psychopathology when first seen.

Individual differences in state-dependent retrieval effects of alcohol intoxication

Individual differences in susceptibility to the state-dependent retrieval (SDR) effects from alcohol in twelve subjects was tested on repeated occasions. There was a threefold variability in frequency of SDR among the subjects. A significant positive correlation between frequency of SDR and history of blackouts and heavy drinking was found.

Is Briquet's syndrome a heterogeneous disorder?

A structured interview that identified 78 female psychiatric outpatients as having Briquet's syndrome also indicated that 77 of the 78 fulfilled inclusive diagnostic criteria for one or more other psychiatric syndromes. If, as this finding suggests, Briquet's syndrome represents a heterogeneous disorder, its various components should be evaluated and patient responses to treatments should be assessed. Until such studies are done, the general and psychiatric physician should be aware that the diagnosis of Briquet's syndrome does not rule out the possibility of other psychiatric illnesses that may be more amenable to treatment.

Lithium compliance in alcoholic males: a six month followup study

One hundred alcoholic patients were followed at monthly outpatient clinics for 6 months. Half were assigned low to moderate doses of lithium carbonate and half to chlordiazepoxide (10 mg tid) (active placebo). Drinking behavior and medication compliance were monitored at monthly clinics. After 6 months 52% of the lithium and 44% of the chlordiazepoxide patients were medication compliant. Of the 48% remaining in the lithium group, 14% did not return for a single visit while 14% came only once. Twenty percent came to clinic regularly; however they had never taken the medication as assigned. Of the 56% non-compliant chlordiazepoxide patients, 16% did not attend a single clinic; 24% came only once or twice and the remaining 16% attended clinics regularly although they were never medication-compliant. Drinking days and the percentage of patients reporting abstinence for one or more months were determined for medication compliant patients and for patients who attended clinic regularly but who did not take medication. Data were analyzed by Kruskal-Wallis one way analysis of variance tests. While lithium and chlordiazepoxide compliant patients tended to report fewer mean drinking days per month (4.6 and 4.8 respectively) than the non-medication group (6.9) these differences were not significant; however, compared to 44% in the non-medication group, 60% of the lithium patients and 58% of the chlordiazepoxide patients reported having significantly more months of abstinence (p less than .05). These results do not show that lithium is differentially efficacious in reducing alcohol consumption.

The discriminate validity of the Psychiatric Diagnostic Interview

The discriminate validity of the Psychiatric Diagnostic Interview (PDI), a criterion-referenced, structured diagnostic instrument, is discussed. Data presented indicate that the PDI has an acceptable level of discriminate ability, making it a useful screening tool for detecting a variety of well-defined psychiatric disorders.

Comparison of three outpatient treatment interventions: a twelve-month follow-up of men alcoholics

Men inpatient alcoholics (N = 174) from a Veterans Administration medical center who were preselected by employment status were randomly assigned to one of three outpatient treatment interventions: (1) medication only, (2) active support or (3) untreated medical monitoring. Subjects were followed monthly for 1 year, with an 85% 12-month follow-up rate. Although the sample as a whole showed reduced alcohol misuse and improved social functioning after 12 months, the specific form of treatment was unrelated to outcome. These findings suggest that the intensity of the outpatient treatment experience is not related to outcome and that time-consuming interventions are not differentially cost-effective.