http://informahealthcare.com/jmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2015; 24(3): 162–167 ! 2015 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2015.1036967
ORIGINAL ARTICLE
Hazardous alcohol use in general psychiatric outpatients Sophia Eberhard, Go¨ran Nordstro¨m, and Agneta O¨jehagen
J Ment Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
Department of Clinical Science, Division of Psychiatry, University Hospital Lund, Lund, Sweden
Abstract
Keywords
Background: Hazardous alcohol use in psychiatric patients may increase the risk of the development of a substance use disorder and negatively affect the course of the psychiatric disorder. Aims: To investigate the prevalence of hazardous alcohol and drug use in a Swedish psychiatric outpatient population with particular focus on hazardous alcohol consumption and assess relationships of hazardous alcohol use to sex, age and psychiatric diagnosis. Methods: General psychiatric outpatients, n ¼ 1,679, completed a self-rating Alcohol Use Disorders Identification Test (AUDIT). Results: Hazardous or harmful alcohol habits occurred among 22% of all women and 30% of all men with higher prevalence among younger patients. Nine percent of all women and 22 % of all men reported binge drinking. Binge drinking was more frequent in younger subjects. Women with a personality disorder diagnosis had a higher frequency of at risk drinking. Apart from that, psychiatric diagnosis was unrelated to rate of hazardous drinking. Conclusions: Hazardous alcohol use was common in this psychiatric outpatient population. With regard to possible risks related to drinking in psychiatric patients, alcohol habits should be assessed as a part of good clinical practice.
Hazardous alcohol use, psychiatry, brief intervention, binge drinking
Introduction The prevalence of substance use disorders among psychiatric patients is high (Jane-Llopis & Matytsina, 2006; Kavanagh et al., 2004). Suffering from a psychiatric disorder more than doubles the lifetime risk of developing an alcohol use disorder (Conway et al., 2006; Grant et al., 2004; Grant & Harford, 1995). A concurrent alcohol use disorder in psychiatric patients worsens outcome and prolongs psychiatric disorder duration (Schuckit, 2006). Hazardous alcohol use has been shown to be a risk factor for developing a substance use disorder in clinical as well as general population samples (Bott et al., 2005; Caetano, 1999; Caetano & Cunradi, 2002; Castaneda et al., 1998). Early identification and intervention in hazardous alcohol use has been shown to be effective in physical health care (Kaner et al., 2013). Hulse & Tait (2002) have suggested that an increased attention to psychiatric patients’ alcohol habits, and the identification of patients with hazardous consumption could help reduce the development of an alcohol use disorder in these patients. There are few studies on frequencies of hazardous alcohol use in psychiatric patients. Hulse & Tait (2002) screened Australian psychiatric in-patients with the Alcohol Use Disorders Identification Test (AUDIT) in 2000, and found that 23% consumed alcohol at a hazardous or harmful level. Correspondence: Sophia Eberhard, Department of Clinical Science, Division of Psychiatry, University Hospital Lund, 221 85 Lund, Sweden. E-mail: [email protected]
History Received 4 December 2013 Revised 15 January 2015 Accepted 21 February 2015
Barnaby et al. (2003) screened all patients in two psychiatric emergency wards in London and reported that 49% scored above cut-off for hazardous alcohol use. Concerning psychiatric outpatients, most studies have been carried out on patients with severe mental illness (Cruce et al., 2007; McCreadie, 2002). Few studies have addressed the topic of alcohol habits in non-psychotic psychiatric outpatients. Satre et al. (2011) examined alcohol use patterns among men and women with depression seeking outpatient psychiatric treatment in the US and reported figures of 48% in men and 33% in women of episodes of heavy drinking. Binge drinking, is captured by item 3 in the AUDIT (How often do you have 6 or more drinks on one occasion?). Several studies in the general population have highlighted the risks related to irregular heavy drinking, e.g. the development of dependence, non-recovery from common mental disorders as well as an increased risk of suicide and suicidal behavior (Andrews & Lewinsohn, 1992; Beautrais, 1998; Caetano, 1999; Caetano & Cunradi, 2002; Dawson et al., 2008; Haynes et al., 2008; Viner & Taylor, 2007). The main aim of this study was to investigate the prevalence of hazardous alcohol and drug use in a Swedish psychiatric outpatient population. The specific aims were to study: (a) frequency of hazardous drinking in relation to psychiatric diagnoses; (b) distribution of hazardous drinking in relation to age and sex;
DOI: 10.3109/09638237.2015.1036967
Hazardous alcohol use in general psychiatric outpatients
(c) frequency of binge drinking in relation to psychiatric diagnoses.
concerns binge drinking. The definition of binge drinking used in this study was having six or more drinks/occasion at least once a month (corresponding to 2 and more points in item 3 of the AUDIT-questionnaire). The DUDIT questionnaire comprises 11 questions that correspond to the AUDIT items (Berman et al., 2005). The maximum score for each item is 4. In a study on the general Swedish population, the preliminary recommendation is a lower cut-off score of 42 for women and 46 for men to identify hazardous drug use (Bergman & Ka¨llme´n, 2002). As the upper cut-off we used 17 for both sexes (Berman et al., 2005). Patients reporting drug habits above the upper cut-off were contacted and treatment was recommended. The study got approval from the Lund University Medical Ethics Committee. Informed consent was obtained from the participating patients.
Patients and methods
J Ment Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
Patients Over a 10-week period in 2004, all patients visiting the 15 adult general psychiatric outpatient units in two regions of Sweden (Lund and Uppsala County), fulfilling the inclusion criteria (see below) were offered screening of their alcohol and drug habits. Upon registration for their routine visit, patients received an envelope containing written information about the study design, an informed-consent form and two self-rating questionnaires (the AUDIT and the Drug Use Disorders Identification Test – DUDIT) (Berman et al., 2005; Saunders et al., 1993). To qualify for inclusion, the patients had to be able to understand written and spoken Swedish. Those with an identified substance use disorder and those judged to be psychiatrically too severely ill to participate were excluded. A total of 1746 patients completed the AUDIT and 1716 completed the DUDIT questionnaire. Sixty-seven patients were excluded from the study (n ¼ 67), 38 patients were excluded as they did not register patient sex. As the screening instrument applies different cut off’s for men and women, the missing sex did not allow us to analyze these results, 29 patients who left more than three questions unanswered were also excluded. When 1–3 questions were not completed (n ¼ 14, AUDIT) missing data were imputed with the mean for this question in the corresponding subgroup for sex and age, as was performed in intervention article from this sample (Eberhard et al, 2009). Another 130 patients misunderstood the questionnaire concerning drug-habits (and reported prescribed tranquilizers), their DUDIT scores were excluded from the analyses. In total, 1679 patients qualified for inclusion in the study. Out of these, 1519 completed the DUDIT questionnaire correctly. All the patients gave consent to access their psychiatric diagnosis. In this study, we used the diagnosis obtained at the visit to the unit when the questionnaires were completed (ICD-10, 2004). Questionnaires The AUDIT was developed by Saunders and Babor in collaboration with the WHO (Saunders et al., 1993) as a screening instrument for hazardous and harmful alcohol consumption and possible dependence (Babor et al., 2001). It consists of 10 questions regarding hazardous alcohol consumption, frequency of intoxication, drinking patterns and adverse consequences. Each question scores between 0 and 4 points, thus the maximum score is 40 points. It has been translated into Swedish and validated by Bergman & Ka¨llme´n (2002). In this study, we used the recommended cut-off scores of 46 for women and 48 for men (Babor et al., 2001). A score of 19 or higher on the AUDIT indicates ‘‘alcoholrelated problems including dependence’’ (Claussen & Aasland, 1993; Donovan et al., 1993). All patients with scores of 19 or higher were contacted and offered information about treatment available. The third item in the AUDIT
163
Statistical analysis The following predefined statistical analyses were carried out using SPSS 15.0 Windows (Chicago, IL). The level of significance was set to p50.05. Differences in proportions were analyzed with the Chi-square test. The Mann– Whitney U-test was applied when continuous data were judged as non-normally distributed. The age difference between men and women was tested by Student’s T-test. For comparisons between AUDIT subscales, a non-parametric variance analysis was used. For testing linearity in the distribution of hazardous drinking, an asymptotic Linear-by-Linear Association Test was used (Shah & Madden, 2004).
Results Patient disposition Ninety-seven percent of the patients visiting the units received the questionnaires. In Lund, the response rate of those who received the envelope was 74%. In Uppsala County, the corresponding data could not be obtained. For the Lund sample, we were able to compare sex ratio and diagnoses in our cohort with the total group of patients visiting the Lund units, concluding that the sample could be regarded as fairly representative. These data were not possible to obtain from Uppsala after enrolment. As psychiatric outpatient care, at the time for enrolment was organized in a comparable way all over Sweden, we estimate that distribution of sex ratio and diagnoses should not differ notably. In total, 1746 patients agreed to take part in the study. The 1065 patients from Lund constituted 71% of all the patients visiting the psychiatric outpatient units in Lund during that period. The 1679 patients, who were qualified for inclusion in the study consisted of 72% women (n ¼ 1207) and 28% men (n ¼ 472), compared to 67% women and 33% men in the total group of patients visiting the Lund units during that period. Thus, the sex ratio in the sample could be regarded as fairly representative regarding the Lund units involved. The mean age in the screening-sample was 37 years for women (SD ¼ 13 years, median 35, range 17–81) and 39 years for men (SD ¼ 14 years, median 37, range 18–79).
164
S. Eberhard et al.
J Ment Health, 2015; 24(3): 162–167
Table 1. Hazardous drug use in two age groups (median years) in men and women.
No/low risk Hazardous drug use
Women 35 years (n ¼ 627)
Women 36 years (n ¼ 468)
Men 36 years (n ¼ 211)
Men 37 years (n ¼ 213)
92.0%, n ¼ 577 8.0%, n ¼ 50
96.5%, n ¼ 452 3.5%, n ¼ 16a
91.9%, n ¼ 194 8.1%, n ¼ 17
97.7%, n ¼ 208 2.3%, n ¼ 5b
Statistics: Chi-square test. a Comparison rates of hazardous use between younger and older women, p ¼ 0.000. b Comparison rates of hazardous use between younger and older men, p50.05.
J Ment Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
Table 2. Distribution of hazardous drinking in age quartiles in men and women (%).
1. Quartile, ,17–26
ORIGINAL ARTICLE
Hazardous alcohol use in general psychiatric outpatients Sophia Eberhard, Go¨ran Nordstro¨m, and Agneta O¨jehagen
J Ment Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
Department of Clinical Science, Division of Psychiatry, University Hospital Lund, Lund, Sweden
Abstract
Keywords
Background: Hazardous alcohol use in psychiatric patients may increase the risk of the development of a substance use disorder and negatively affect the course of the psychiatric disorder. Aims: To investigate the prevalence of hazardous alcohol and drug use in a Swedish psychiatric outpatient population with particular focus on hazardous alcohol consumption and assess relationships of hazardous alcohol use to sex, age and psychiatric diagnosis. Methods: General psychiatric outpatients, n ¼ 1,679, completed a self-rating Alcohol Use Disorders Identification Test (AUDIT). Results: Hazardous or harmful alcohol habits occurred among 22% of all women and 30% of all men with higher prevalence among younger patients. Nine percent of all women and 22 % of all men reported binge drinking. Binge drinking was more frequent in younger subjects. Women with a personality disorder diagnosis had a higher frequency of at risk drinking. Apart from that, psychiatric diagnosis was unrelated to rate of hazardous drinking. Conclusions: Hazardous alcohol use was common in this psychiatric outpatient population. With regard to possible risks related to drinking in psychiatric patients, alcohol habits should be assessed as a part of good clinical practice.
Hazardous alcohol use, psychiatry, brief intervention, binge drinking
Introduction The prevalence of substance use disorders among psychiatric patients is high (Jane-Llopis & Matytsina, 2006; Kavanagh et al., 2004). Suffering from a psychiatric disorder more than doubles the lifetime risk of developing an alcohol use disorder (Conway et al., 2006; Grant et al., 2004; Grant & Harford, 1995). A concurrent alcohol use disorder in psychiatric patients worsens outcome and prolongs psychiatric disorder duration (Schuckit, 2006). Hazardous alcohol use has been shown to be a risk factor for developing a substance use disorder in clinical as well as general population samples (Bott et al., 2005; Caetano, 1999; Caetano & Cunradi, 2002; Castaneda et al., 1998). Early identification and intervention in hazardous alcohol use has been shown to be effective in physical health care (Kaner et al., 2013). Hulse & Tait (2002) have suggested that an increased attention to psychiatric patients’ alcohol habits, and the identification of patients with hazardous consumption could help reduce the development of an alcohol use disorder in these patients. There are few studies on frequencies of hazardous alcohol use in psychiatric patients. Hulse & Tait (2002) screened Australian psychiatric in-patients with the Alcohol Use Disorders Identification Test (AUDIT) in 2000, and found that 23% consumed alcohol at a hazardous or harmful level. Correspondence: Sophia Eberhard, Department of Clinical Science, Division of Psychiatry, University Hospital Lund, 221 85 Lund, Sweden. E-mail: [email protected]
History Received 4 December 2013 Revised 15 January 2015 Accepted 21 February 2015
Barnaby et al. (2003) screened all patients in two psychiatric emergency wards in London and reported that 49% scored above cut-off for hazardous alcohol use. Concerning psychiatric outpatients, most studies have been carried out on patients with severe mental illness (Cruce et al., 2007; McCreadie, 2002). Few studies have addressed the topic of alcohol habits in non-psychotic psychiatric outpatients. Satre et al. (2011) examined alcohol use patterns among men and women with depression seeking outpatient psychiatric treatment in the US and reported figures of 48% in men and 33% in women of episodes of heavy drinking. Binge drinking, is captured by item 3 in the AUDIT (How often do you have 6 or more drinks on one occasion?). Several studies in the general population have highlighted the risks related to irregular heavy drinking, e.g. the development of dependence, non-recovery from common mental disorders as well as an increased risk of suicide and suicidal behavior (Andrews & Lewinsohn, 1992; Beautrais, 1998; Caetano, 1999; Caetano & Cunradi, 2002; Dawson et al., 2008; Haynes et al., 2008; Viner & Taylor, 2007). The main aim of this study was to investigate the prevalence of hazardous alcohol and drug use in a Swedish psychiatric outpatient population. The specific aims were to study: (a) frequency of hazardous drinking in relation to psychiatric diagnoses; (b) distribution of hazardous drinking in relation to age and sex;
DOI: 10.3109/09638237.2015.1036967
Hazardous alcohol use in general psychiatric outpatients
(c) frequency of binge drinking in relation to psychiatric diagnoses.
concerns binge drinking. The definition of binge drinking used in this study was having six or more drinks/occasion at least once a month (corresponding to 2 and more points in item 3 of the AUDIT-questionnaire). The DUDIT questionnaire comprises 11 questions that correspond to the AUDIT items (Berman et al., 2005). The maximum score for each item is 4. In a study on the general Swedish population, the preliminary recommendation is a lower cut-off score of 42 for women and 46 for men to identify hazardous drug use (Bergman & Ka¨llme´n, 2002). As the upper cut-off we used 17 for both sexes (Berman et al., 2005). Patients reporting drug habits above the upper cut-off were contacted and treatment was recommended. The study got approval from the Lund University Medical Ethics Committee. Informed consent was obtained from the participating patients.
Patients and methods
J Ment Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
Patients Over a 10-week period in 2004, all patients visiting the 15 adult general psychiatric outpatient units in two regions of Sweden (Lund and Uppsala County), fulfilling the inclusion criteria (see below) were offered screening of their alcohol and drug habits. Upon registration for their routine visit, patients received an envelope containing written information about the study design, an informed-consent form and two self-rating questionnaires (the AUDIT and the Drug Use Disorders Identification Test – DUDIT) (Berman et al., 2005; Saunders et al., 1993). To qualify for inclusion, the patients had to be able to understand written and spoken Swedish. Those with an identified substance use disorder and those judged to be psychiatrically too severely ill to participate were excluded. A total of 1746 patients completed the AUDIT and 1716 completed the DUDIT questionnaire. Sixty-seven patients were excluded from the study (n ¼ 67), 38 patients were excluded as they did not register patient sex. As the screening instrument applies different cut off’s for men and women, the missing sex did not allow us to analyze these results, 29 patients who left more than three questions unanswered were also excluded. When 1–3 questions were not completed (n ¼ 14, AUDIT) missing data were imputed with the mean for this question in the corresponding subgroup for sex and age, as was performed in intervention article from this sample (Eberhard et al, 2009). Another 130 patients misunderstood the questionnaire concerning drug-habits (and reported prescribed tranquilizers), their DUDIT scores were excluded from the analyses. In total, 1679 patients qualified for inclusion in the study. Out of these, 1519 completed the DUDIT questionnaire correctly. All the patients gave consent to access their psychiatric diagnosis. In this study, we used the diagnosis obtained at the visit to the unit when the questionnaires were completed (ICD-10, 2004). Questionnaires The AUDIT was developed by Saunders and Babor in collaboration with the WHO (Saunders et al., 1993) as a screening instrument for hazardous and harmful alcohol consumption and possible dependence (Babor et al., 2001). It consists of 10 questions regarding hazardous alcohol consumption, frequency of intoxication, drinking patterns and adverse consequences. Each question scores between 0 and 4 points, thus the maximum score is 40 points. It has been translated into Swedish and validated by Bergman & Ka¨llme´n (2002). In this study, we used the recommended cut-off scores of 46 for women and 48 for men (Babor et al., 2001). A score of 19 or higher on the AUDIT indicates ‘‘alcoholrelated problems including dependence’’ (Claussen & Aasland, 1993; Donovan et al., 1993). All patients with scores of 19 or higher were contacted and offered information about treatment available. The third item in the AUDIT
163
Statistical analysis The following predefined statistical analyses were carried out using SPSS 15.0 Windows (Chicago, IL). The level of significance was set to p50.05. Differences in proportions were analyzed with the Chi-square test. The Mann– Whitney U-test was applied when continuous data were judged as non-normally distributed. The age difference between men and women was tested by Student’s T-test. For comparisons between AUDIT subscales, a non-parametric variance analysis was used. For testing linearity in the distribution of hazardous drinking, an asymptotic Linear-by-Linear Association Test was used (Shah & Madden, 2004).
Results Patient disposition Ninety-seven percent of the patients visiting the units received the questionnaires. In Lund, the response rate of those who received the envelope was 74%. In Uppsala County, the corresponding data could not be obtained. For the Lund sample, we were able to compare sex ratio and diagnoses in our cohort with the total group of patients visiting the Lund units, concluding that the sample could be regarded as fairly representative. These data were not possible to obtain from Uppsala after enrolment. As psychiatric outpatient care, at the time for enrolment was organized in a comparable way all over Sweden, we estimate that distribution of sex ratio and diagnoses should not differ notably. In total, 1746 patients agreed to take part in the study. The 1065 patients from Lund constituted 71% of all the patients visiting the psychiatric outpatient units in Lund during that period. The 1679 patients, who were qualified for inclusion in the study consisted of 72% women (n ¼ 1207) and 28% men (n ¼ 472), compared to 67% women and 33% men in the total group of patients visiting the Lund units during that period. Thus, the sex ratio in the sample could be regarded as fairly representative regarding the Lund units involved. The mean age in the screening-sample was 37 years for women (SD ¼ 13 years, median 35, range 17–81) and 39 years for men (SD ¼ 14 years, median 37, range 18–79).
164
S. Eberhard et al.
J Ment Health, 2015; 24(3): 162–167
Table 1. Hazardous drug use in two age groups (median years) in men and women.
No/low risk Hazardous drug use
Women 35 years (n ¼ 627)
Women 36 years (n ¼ 468)
Men 36 years (n ¼ 211)
Men 37 years (n ¼ 213)
92.0%, n ¼ 577 8.0%, n ¼ 50
96.5%, n ¼ 452 3.5%, n ¼ 16a
91.9%, n ¼ 194 8.1%, n ¼ 17
97.7%, n ¼ 208 2.3%, n ¼ 5b
Statistics: Chi-square test. a Comparison rates of hazardous use between younger and older women, p ¼ 0.000. b Comparison rates of hazardous use between younger and older men, p50.05.
J Ment Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
Table 2. Distribution of hazardous drinking in age quartiles in men and women (%).
1. Quartile, ,17–26
