alcohol dependence case study

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Evidence-based models of care for the treatment of alcohol use disorder in primary health care settings: protocol for systematic review

• Susan A. Rombouts 1 ,
• James Conigrave 2 ,
• Eva Louie 1 ,
• Paul Haber 1 , 3 &
• Kirsten C. Morley   ORCID: orcid.org/0000-0002-0868-9928 1  

Systematic Reviews volume  8 , Article number:  275 ( 2019 ) Cite this article

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Alcohol use disorder (AUD) is highly prevalent and accounts globally for 1.6% of disability-adjusted life years (DALYs) among females and 6.0% of DALYs among males. Effective treatments for AUDs are available but are not commonly practiced in primary health care. Furthermore, referral to specialized care is often not successful and patients that do seek treatment are likely to have developed more severe dependence. A more cost-efficient health care model is to treat less severe AUD in a primary care setting before the onset of greater dependence severity. Few models of care for the management of AUD in primary health care have been developed and with limited implementation. This proposed systematic review will synthesize and evaluate differential models of care for the management of AUD in primary health care settings.

We will conduct a systematic review to synthesize studies that evaluate the effectiveness of models of care in the treatment of AUD in primary health care. A comprehensive search approach will be conducted using the following databases; MEDLINE (1946 to present), PsycINFO (1806 to present), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL) (1991 to present), and Embase (1947 to present).

Reference searches of relevant reviews and articles will be conducted. Similarly, a gray literature search will be done with the help of Google and the gray matter tool which is a checklist of health-related sites organized by topic. Two researchers will independently review all titles and abstracts followed by full-text review for inclusion. The planned method of extracting data from articles and the critical appraisal will also be done in duplicate. For the critical appraisal, the Cochrane risk of bias tool 2.0 will be used.

This systematic review and meta-analysis aims to guide improvement of design and implementation of evidence-based models of care for the treatment of alcohol use disorder in primary health care settings. The evidence will define which models are most promising and will guide further research.

Protocol registration number

PROSPERO CRD42019120293.

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It is well recognized that alcohol use disorders (AUD) have a damaging impact on the health of the population. According to the World Health Organization (WHO), 5.3% of all global deaths were attributable to alcohol consumption in 2016 [ 1 ]. The 2016 Global Burden of Disease Study reported that alcohol use led to 1.6% (95% uncertainty interval [UI] 1.4–2.0) of total DALYs globally among females and 6.0% (5.4–6.7) among males, resulting in alcohol use being the seventh leading risk factor for both premature death and disability-adjusted life years (DALYs) [ 2 ]. Among people aged 15–49 years, alcohol use was the leading risk factor for mortality and disability with 8.9% (95% UI 7.8–9.9) of all attributable DALYs for men and 2.3% (2.0–2.6) for women [ 2 ]. AUD has been linked to many physical and mental health complications, such as coronary heart disease, liver cirrhosis, a variety of cancers, depression, anxiety, and dementia [ 2 , 3 ]. Despite the high morbidity and mortality rate associated with hazardous alcohol use, the global prevalence of alcohol use disorders among persons aged above 15 years in 2016 was stated to be 5.1% (2.5% considered as harmful use and 2.6% as severe AUD), with the highest prevalence in the European and American region (8.8% and 8.2%, respectively) [ 1 ].

Effective and safe treatment for AUD is available through psychosocial and/or pharmacological interventions yet is not often received and is not commonly practiced in primary health care. While a recent European study reported 8.7% prevalence of alcohol dependence in primary health care populations [ 4 ], the vast majority of patients do not receive the professional treatment needed, with only 1 in 5 patients with alcohol dependence receiving any formal treatment [ 4 ]. In Australia, it is estimated that only 3% of individuals with AUD receive approved pharmacotherapy for the disorder [ 5 , 6 ]. Recognition of AUD in general practice uncommonly leads to treatment before severe medical and social disintegration [ 7 ]. Referral to specialized care is often not successful, and those patients that do seek treatment are likely to have more severe dependence with higher levels of alcohol use and concurrent mental and physical comorbidity [ 4 ].

Identifying and treating early stage AUDs in primary care settings can prevent condition worsening. This may reduce the need for more complex and more expensive specialized care. The high prevalence of AUD in primary health care and the chronic relapsing character of AUD make primary care a suitable and important location for implementing evidence-based interventions. Successful implementation of treatment models requires overcoming multiple barriers. Qualitative studies have identified several of those barriers such as limited time, limited organizational capacity, fear of losing patients, and physicians feeling incompetent in treating AUD [ 8 , 9 , 10 ]. Additionally, a recent systematic review revealed that diagnostic sensitivity of primary care physicians in the identification of AUD was 41.7% and that only in 27.3% alcohol problems were recorded correctly in primary care records [ 11 ].

Several models for primary care have been created to increase identification and treatment of patients with AUD. Of those, the model, screening, brief interventions, and referral to specialized treatment for people with severe AUD (SBIRT [ 12 ]) is most well-known. Multiple systematic reviews exist, confirming its effectiveness [ 13 , 14 , 15 ], although implementation in primary care has been inadequate. Moreover, most studies have looked primarily at SBIRT for the treatment of less severe AUD [ 16 ]. In the treatment of severe AUD, efficacy of SBIRT is limited [ 16 ]. Additionally, many patient referred to specialized care often do not attend as they encounter numerous difficulties in health care systems including stigmatization, costs, lack of information about existing treatments, and lack of non-abstinence-treatment goals [ 7 ]. An effective model of care for improved management of AUD that can be efficiently implemented in primary care settings is required.

Review objective

This proposed systematic review will synthesize and evaluate differential models of care for the management of AUD in primary health care settings. We aim to evaluate the effectiveness of the models of care in increasing engagement and reducing alcohol consumption.

By providing this overview, we aim to guide improvement of design and implementation of evidence-based models of care for the treatment of alcohol use disorder in primary health care settings.

The systematic review is registered in PROSPERO international prospective register of systematic reviews (CRD42019120293) and the current protocol has been written according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) recommended for systematic reviews [ 17 ]. A PRISMA-P checklist is included as Additional file  1 .

Eligibility criteria

Criteria for considering studies for this review are classified by the following:

Study design

Both individualized and cluster randomized trials will be included. Masking of patients and/or physicians is not an inclusion criterion as it is often hard to accomplish in these types of studies.

Patients in primary health care who are identified (using screening tools or by primary health care physician) as suffering from AUD (from mild to severe) or hazardous alcohol drinking habits (e.g., comorbidity, concurrent medication use). Eligible patients need to have had formal assessment of AUD with diagnostic tools such as Diagnostic and Statistical Manual of Mental Disorders (DSM-IV/V) or the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and/or formal assessment of hazardous alcohol use assessed by the Comorbidity Alcohol Risk Evaluation Tool (CARET) or the Alcohol Use Disorders Identification test (AUDIT) and/or alcohol use exceeding guideline recommendations to reduce health risks (e.g., US dietary guideline (2015–2020) specifies excessive drinking for women as ≥ 4 standard drinks (SD) on any day and/or ≥ 8 SD per week and for men ≥ 5 SD on any day and/or ≥ 15 SD per week).

Studies evaluating models of care for additional diseases (e.g., other dependencies/mental health) other than AUD are included when they have conducted data analysis on the alcohol use disorder patient data separately or when 80% or more of the included patients have AUD.

Intervention

The intervention should consist of a model of care; therefore, it should include multiple components and cover different stages of the care pathway (e.g., identification of patients, training of staff, modifying access to resources, and treatment). An example is the Chronic Care Model (CCM) which is a primary health care model designed for chronic (relapsing) conditions and involves six elements: linkage to community resources, redesign of health care organization, self-management support, delivery system redesign (e.g., use of non-physician personnel), decision support, and the use of clinical information systems [ 18 , 19 ].

As numerous articles have already assessed the treatment model SBIRT, this model of care will be excluded from our review unless the particular model adds a specific new aspect. Also, the article has to assess the effectiveness of the model rather than assessing the effectiveness of the particular treatment used. Because identification of patients is vital to including them in the trial, a care model that only evaluates either patient identification or treatment without including both will be excluded from this review.

Model effectiveness may be in comparison with the usual care or a different treatment model.

Included studies need to include at least one of the following outcome measures: alcohol consumption, treatment engagement, uptake of pharmacological agents, and/or quality of life.

Solely quantitative research will be included in this systematic review (e.g., randomized controlled trials (RCTs) and cluster RCTs). We will only include peer-reviewed articles.

Restrictions (language/time period)

Studies published in English after 1 January 1998 will be included in this systematic review.

Studies have to be conducted in primary health care settings as such treatment facilities need to be physically in or attached to the primary care clinic. Examples are co-located clinics, veteran health primary care clinic, hospital-based primary care clinic, and community primary health clinics. Specialized primary health care clinics such as human immunodeficiency virus (HIV) clinics are excluded from this systematic review. All studies were included, irrespective of country of origin.

Search strategy and information sources

A comprehensive search will be conducted. The following databases will be consulted: MEDLINE (1946 to present), PsycINFO (1806 to present), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL) (1991 to present), and Embase (1947 to present). Initially, the search terms will be kept broad including alcohol use disorder (+synonyms), primary health care, and treatment to minimize the risk of missing any potentially relevant articles. Depending on the number of references attained by this preliminary search, we will add search terms referring to models such as models of care, integrated models, and stepped-care models, to limit the number of articles. Additionally, we will conduct reference searches of relevant reviews and articles. Similarly, a gray literature search will be done with the help of Google and the Gray Matters tool which is a checklist of health-related sites organized by topic. The tool is produced by the Canadian Agency for Drugs and Technologies in Health (CADTH) [ 20 ].

See Additional file  2 for a draft of our search strategy in MEDLINE.

Data collection

The selection of relevant articles is based on several consecutive steps. All references will be managed using EndNote (EndNote version X9 Clarivate Analytics). Initially, duplicates will be removed from the database after which all the titles will be screened with the purpose of discarding clearly irrelevant articles. The remaining records will be included in an abstract and full-text screen. All steps will be done independently by two researchers. Disagreement will lead to consultation of a third researcher.

Data extraction and synthesis

Two researchers will extract data from included records. At the conclusion of data extraction, these two researchers will meet with the lead author to resolve any discrepancies.

In order to follow a structured approach, an extraction form will be used. Key elements of the extraction form are information about design of the study (randomized, blinded, control), type of participants (alcohol use, screening tool used, socio-economic status, severity of alcohol use, age, sex, number of participants), study setting (primary health care setting, VA centers, co-located), type of intervention/model of care (separate elements of the models), type of health care worker (primary, secondary (co-located)), duration of follow-up, outcome measures used in the study, and funding sources. We do not anticipate having sufficient studies for a meta-analysis. As such, we plan to perform a narrative synthesis. We will synthesize the findings from the included articles by cohort characteristics, differential aspects of the intervention, controls, and type of outcome measures.

Sensitivity analyses will be conducted when issues suitable for sensitivity analysis are identified during the review process (e.g., major differences in quality of the included articles).

Potential meta-analysis

In the event that sufficient numbers of effect sizes can be extracted, a meta-analytic synthesis will be performed. We will extract effect sizes from each study accordingly. Two effect sizes will be extracted (and transformed where appropriate). Categorical outcomes will be given in log odds ratios and continuous measures will be converted into standardized mean differences. Variation in effect sizes attributable to real differences (heterogeneity) will be estimated using the inconsistency index ( I 2 ) [ 21 , 22 ]. We anticipate high degrees of variation among effect sizes, as a result moderation and subgroup-analyses will be employed as appropriate. In particular, moderation analysis will focus on the degree of heterogeneity attributable to differences in cohort population (pre-intervention drinking severity, age, etc.), type of model/intervention, and study quality. We anticipate that each model of care will require a sub-group analysis, in which case a separate meta-analysis will be performed for each type of model. Small study effect will be assessed with funnel plots and Egger’s symmetry tests [ 23 ]. When we cannot obtain enough effect sizes for synthesis or when the included studies are too diverse, we will aim to illustrate patterns in the data by graphical display (e.g., bubble plot) [ 24 ].

Critical appraisal of studies

All studies will be critically assessed by two researchers independently using the Revised Cochrane risk-of-bias tool (RoB 2) [ 25 ]. This tool facilitates systematic assessment of the quality of the article per outcome according to the five domains: bias due to (1) the randomization process, (2) deviations from intended interventions, (3) missing outcome data, (4) measurement of the outcome, and (5) selection of the reported results. An additional domain 1b must be used when assessing the randomization process for cluster-randomized studies.

Meta-biases such as outcome reporting bias will be evaluated by determining whether the protocol was published before recruitment of patients. Additionally, trial registries will be checked to determine whether the reported outcome measures and statistical methods are similar to the ones described in the registry. The gray literature search will be of assistance when checking for publication bias; however, completely eliminating the presence of publication bias is impossible.

Similar to article selection, any disagreement between the researchers will lead to discussion and consultation of a third researcher. The strength of the evidence will be graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach [ 26 ].

The primary outcome measure of this proposed systematic review is the consumption of alcohol at follow-up. Consumption of alcohol is often quantified in drinking quantity (e.g., number of drinks per week), drinking frequency (e.g., percentage of days abstinent), binge frequency (e.g., number of heavy drinking days), and drinking intensity (e.g., number of drinks per drinking day). Additionally, outcomes such as percentage/proportion included patients that are abstinent or considered heavy/risky drinkers at follow-up. We aim to report all these outcomes. The consumption of alcohol is often self-reported by patients. When studies report outcomes at multiple time points, we will consider the longest follow-up of individual studies as a primary outcome measure.

Depending on the included studies, we will also consider secondary outcome measures such as treatment engagement (e.g., number of visits or pharmacotherapy uptake), economic outcome measures, health care utilization, quality of life assessment (physical/mental), alcohol-related problems/harm, and mental health score for depression or anxiety.

This proposed systematic review will synthesize and evaluate differential models of care for the management of AUD in primary health care settings.

Given the complexities of researching models of care in primary care and the paucity of a focus on AUD treatment, there are likely to be only a few studies that sufficiently address the research question. Therefore, we will do a preliminary search without the search terms for model of care. Additionally, the search for online non-academic studies presents a challenge. However, the Gray Matters tool will be of guidance and will limit the possibility of missing useful studies. Further, due to diversity of treatment models, outcome measures, and limitations in research design, it is possible that a meta-analysis for comparative effectiveness may not be appropriate. Moreover, in the absence of large, cluster randomized controlled trials, it will be difficult to distinguish between the effectiveness of the treatment given and that of the model of care and/or implementation procedure. Nonetheless, we will synthesize the literature and provide a critical evaluation of the quality of the evidence.

This review will assist the design and implementation of models of care for the management of AUD in primary care settings. This review will thus improve the management of AUD in primary health care and potentially increase the uptake of evidence-based interventions for AUD.

Availability of data and materials

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Abbreviations

Alcohol use disorder

Alcohol Use Disorders Identification test

Canadian Agency for Drugs and Technologies in Health

The Comorbidity Alcohol Risk Evaluation

Cochrane Central Register of Controlled Trials

Diagnostic and Statistical Manual of Mental Disorders

Human immunodeficiency virus

10 - International Statistical Classification of Diseases and Related Health Problems

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols

Screening, brief intervention, referral to specialized treatment

Standard drinks

World Health Organization

WHO. Global status report on alcohol and health: World health organization; 2018.

The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990–2016. a systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry. 2018;5(12):987–1012.

Article   Google Scholar  

WHO. Global strategy to reduce the harmful use of alcohol: World health organization; 2010.

Rehm J, Allamani A, Elekes Z, Jakubczyk A, Manthey J, Probst C, et al. Alcohol dependence and treatment utilization in Europe - a representative cross-sectional study in primary care. BMC Fam Pract. 2015;16:90.

Morley KC, Logge W, Pearson SA, Baillie A, Haber PS. National trends in alcohol pharmacotherapy: findings from an Australian claims database. Drug Alcohol Depend. 2016;166:254–7.

Article   CAS   Google Scholar  

Morley KC, Logge W, Pearson SA, Baillie A, Haber PS. Socioeconomic and geographic disparities in access to pharmacotherapy for alcohol dependence. J Subst Abus Treat. 2017;74:23–5.

Rehm J, Anderson P, Manthey J, Shield KD, Struzzo P, Wojnar M, et al. Alcohol use disorders in primary health care: what do we know and where do we go? Alcohol Alcohol. 2016;51(4):422–7.

Le KB, Johnson JA, Seale JP, Woodall H, Clark DC, Parish DC, et al. Primary care residents lack comfort and experience with alcohol screening and brief intervention: a multi-site survey. J Gen Intern Med. 2015;30(6):790–6.

McLellan AT, Starrels JL, Tai B, Gordon AJ, Brown R, Ghitza U, et al. Can substance use disorders be managed using the chronic care model? review and recommendations from a NIDA consensus group. Public Health Rev. 2014;35(2).

Storholm ED, Ober AJ, Hunter SB, Becker KM, Iyiewuare PO, Pham C, et al. Barriers to integrating the continuum of care for opioid and alcohol use disorders in primary care: a qualitative longitudinal study. J Subst Abus Treat. 2017;83:45–54.

Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis. Br J Psychiatry. 2012;201:93–100.

Babor TF, Ritson EB, Hodgson RJ. Alcohol-related problems in the primary health care setting: a review of early intervention strategies. Br J Addict. 1986;81(1):23–46.

Kaner EF, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007;(2):Cd004148.

O'Donnell A, Anderson P, Newbury-Birch D, Schulte B, Schmidt C, Reimer J, et al. The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews. Alcohol Alcohol. 2014;49(1):66–78.

Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med. 2005;165(9):986–95.

Saitz R. ‘SBIRT’ is the answer? Probably not. Addiction. 2015;110(9):1416–7.

Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. Bmj. 2015;350:g7647.

Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. Jama. 2002;288(14):1775–9.

Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. Jama. 2002;288(15):1909–14.

CADTH. Grey Matters: a practical tool for searching health-related grey literature Internet. 2018 (cited 2019 Feb 22).

Higgins JPT. Thompson SG. Quantifying heterogeneity in a meta-analysis. 2002;21(11):1539–58.

Google Scholar  

Higgins JPT, Thompson SG, Deeks JJ. Altman DG. Measuring inconsistency in meta-analyses. 2003;327(7414):557–60.

Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ (Clinical research ed). 1997;315(7109):629–34.

Higgins JPT, López-López JA, Becker BJ, Davies SR, Dawson S, Grimshaw JM, et al. Synthesising quantitative evidence in systematic reviews of complex health interventions. BMJ Glob Health. 2019;4(Suppl 1):e000858–e.

Higgins, J.P.T., Sterne, J.A.C., Savović, J., Page, M.J., Hróbjartsson, A., Boutron, I., Reeves, B., Eldridge, S. (2016). A revised tool for assessing risk of bias in randomized trials. In: Chandler, J., McKenzie, J., Boutron, I., Welch, V. (editors). Cochrane methods. Cochrane database of systematic reviews, 10 (Suppl 1). https://doi.org/10.1002/14651858.CD201601 .

Schünemann H, Brożek J, Guyatt G, Oxman A, editor(s). Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach (updated October 2013). GRADE Working Group, 2013. Available from gdt.guidelinedevelopment.org/app/handbook/handbook.html ).

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Discipline of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia

Susan A. Rombouts, Eva Louie, Paul Haber & Kirsten C. Morley

NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia

James Conigrave

Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia

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Contributions

KM and PH conceived the presented idea of a systematic review and meta-analysis and helped with the scope of the literature. KM is the senior researcher providing overall guidance and the guarantor of this review. SR developed the background, search strategy, and data extraction form. SR and EL will both be working on the data extraction and risk of bias assessment. SR and JC will conduct the data analysis and synthesize the results. All authors read and approved the final manuscript.

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Correspondence to Kirsten C. Morley .

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Supplementary information

Additional file 1..

PRISMA-P 2015 Checklist.

Additional file 2.

Draft search strategy MEDLINE. Search strategy.

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Rombouts, S.A., Conigrave, J., Louie, E. et al. Evidence-based models of care for the treatment of alcohol use disorder in primary health care settings: protocol for systematic review. Syst Rev 8 , 275 (2019). https://doi.org/10.1186/s13643-019-1157-7

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Introduction, subjects and methods.

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RISK FACTORS FOR ALCOHOL DEPENDENCE: A CASE-CONTROL STUDY

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Kari Poikolainen, RISK FACTORS FOR ALCOHOL DEPENDENCE: A CASE-CONTROL STUDY, Alcohol and Alcoholism , Volume 35, Issue 2, March 2000, Pages 190–196, https://doi.org/10.1093/alcalc/35.2.190

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Several possible risk factors for ICD-10 alcohol dependence were studied by comparing cases (117 men, 188 women) with controls (248 men, 300 women). Logistic regression analyses showed that parental alcohol problems and high trait anxiety were significantly related to high occurrence of alcohol dependence in both men and women. In women, high antisocial behaviour, high impulsivity, and high externality were also related to high occurrence of alcohol dependence. High facial flushing and high stimulation when intoxicated were related to low occurrence of alcohol dependence in both men and women. In men, this was also the case for high social support. Several interactions were observed. In contrast to earlier studies, there was no significant association between alcohol dependence and left-handedness.

Earlier research has revealed at least five risk factors for alcoholism: family history of alcohol problems, lack of facial flushing, low responsivity, antisocial behaviour, and cultural background. Much of the prospective evidence is based on studies with small numbers of alcoholics ( McCord and McCord, 1960 ; Robins et al ., 1962 ; Vaillant and Milofsky, 1982 ; Vaillant, 1984 ; Schuckit, 1994 ) and the interpretation of these findings is undermined by variation in the number of other factors controlled for in the analysis and the definition of the outcome and the diagnostic criteria. Several earlier studies have combined two diagnostic categories, alcohol dependence and alcohol abuse, into one overall outcome variable ( Vaillant, 1984 ; Spak et al ., 1997 ). This is problematic, because the diagnosis of alcohol dependence is fairly reliable, whereas that of alcohol abuse is not ( Schuckit et al ., 1994 ).

Thus firstly, it is known that alcoholism runs in families and is partly inherited ( Vaillant, 1984 ; Merikangas et al ., 1994 ; Cadoret et al ., 1995 ). Recent research has shown that this is also true for DSM-III-R ( American Psychiatric Association, 1987 ) alcohol dependence ( Dawson et al ., 1992 ; Kendler et al ., 1995 ). It is not known what exactly is inherited ( Gordis, 1996 ). Secondly, the risk of alcoholism is partly related to alcohol-induced facial flushing, in its strong form due to the deficiency and differences in the genotypes of aldehyde dehydrogenase among some Oriental subjects, but found also in a weaker form among some White subjects ( Ward et al ., 1994 ; Whitfield et al ., 1998 ). Thirdly, low responsivity to alcohol has been found to predict the incidence of alcoholic outcome (alcohol abuse and alcohol dependence) in a follow-up study ( Schuckit, 1994 ; Schuckit and Smith, 1996 ). Fourthly, pre-morbid antisocial behaviour has been found to predict alcoholism ( McCord and McCord, 1960 ; Vaillant and Milofsky, 1982 ; Lewis and Bucholz, 1991 ; Miller, 1991 ; Cadoret et al ., 1995 ). Fifthly, cultural background also has predictive power ( Vaillant and Milofsky, 1982 ).

In addition to the known risk factors for alcoholism, there are several other possible candidates. Trait anxiety has been found to be associated with susceptibility to heavy alcohol use among adolescents ( Colder and Chassin, 1993 ), with craving for alcohol among alcoholics ( McCusker and Brown, 1991 ), and to predict alcohol dependence longitudinally ( Heath et al ., 1997 ). Moreover, anxiety disorder has been found to be a risk factor for alcohol dependence in a follow-up study ( Kushner et al ., 1999 ). Alcohol use has been found to be predicted by such personality variables as pre-delinquency, rebelliousness, impulsivity, and sensation seeking ( Brook et al ., 1995 ). High external control scores in adolescence have been found to predict heavy alcohol use in young adulthood for both males and females ( Steele et al ., 1995 ). Social support ( Ohannessian and Hesselbrock, 1993 ), social desirability ( Yoshino and Kato, 1995 ), and left-handedness ( Bakan, 1973 ; McNamara et al ., 1994 ) have also been found to be associated with problem drinking or alcoholism. The role of these factors in the aetiology of alcohol dependence remains to be clarified. The present case-control study aimed to examine which of the above correlates of heavy alcohol use, problem drinking or alcoholism remain(s) associated with alcohol dependence, defined by the ICD-10 criteria ( World Health Organization, 1992 ) after controlling for the known risk factors in a culturally homogeneous population.

The case series was collected from the Järvenpää Addiction Hospital between April 1995 and March 1997. To be eligible, the patients had to meet the ICD-10 criteria for alcohol dependence ( World Health Organization, 1992 ), and withdrawal treatment needed to have been completed before the patients were admitted for in-patient treatment. Of those meeting the criteria, 49% gave their informed consent and responded. The case series comprised 117 men and 188 women. Of the subjects, 33.3% of the men and 38.3% of the women were married. The mean age (SD) was 37.7 (8.6) years for men and 41.8 (8.9) years for women. The age range was 19–72 years. No misuse of substances other than alcohol was reported. The study was approved by the Ethics Committee of the A-Clinic Foundation.

The controls were household members aged 18 years or more from a sample stratified to represent Finnish households in January 1996. Sampling and characteristics of the subjects have been described earlier ( Poikolainen, 1997 ). The response rate was 68–72%. The 66 subjects meeting the ICD-10 criteria for alcohol dependence were excluded from the control series. Thus, the control series comprised 248 men and 300 women. The percentage of married subjects was 59.7 among both males and females. The mean age (SD) was 43.2 (14.7) years for men and 44.7 (14.6) years for women. The age range was 19–81 years. One subject reported misuse of cannabis and another misuse of sedative drugs. Neither met the ICD-10 criteria for substance dependence.

Diagnosis of alcohol dependence.

Questions used to operationalize the diagnosis of alcohol dependence according to both ICD-10 criteria have been described in detail earlier ( Caetano and Tam, 1995 ). There were 10 questions altogether. These questions pertained to the previous 12 months.

Parental history and facial flushing.

Parental history of drinking problems was assessed by asking whether the parents of the respondents had ever had drinking problems or had been in treatment because of these. The test–retest reliability for classification of first-degree relatives has been found to be good, while data for second-degree relatives is considerably less reliable ( Worobec et al ., 1990 ). Tendency to facial flushing was measured by one question on an 11-point scale.

Perceived effects of alcohol intoxication.

The Anticipated Bisphasic Alcohol Effects Scale was used to measure perceived degree of alcohol-induced stimulation and sedation during the last recalled instance of alcohol intoxication. This scale was chosen to yield information on the level of response to alcohol, measured in earlier work by self-reports on the degree of intoxication after exposure to alcohol ( Schuckit, 1994 ). The 11-point scale comprises two 7-item subscales, one on the stimulant effects of alcohol and another on its sedative effects. These subscales have been found to have high internal consistency during both the ascending and descending arms of the blood-alcohol curve ( Martin et al ., 1993 ).

Trait anxiety.

The trait part of the State-Trait Anxiety Inventory was used to measure anxiety as a relatively stable behavioural predisposition ( Spielberger et al ., 1970 ). It has good psychometric validity and reliability ( Bech et al ., 1993 ).

Antisocial behaviour.

Three subscales from the Karolinska Scales of Personality ( Knorring et al ., 1987 ), monotony avoidance, impulsiveness, and socialization, were used to map out antisocial personality styles. The socialization scale was inverted into the antisocialization scale. The scales are fairly independent of the state of the subject ( Knorring et al ., 1987 ). Factor analyses have suggested that scales of monotony avoidance, impulsiveness, and socialization combine into a common factor that has been called the impulsive sensation-seeking psychopathy factor ( Knorring et al ., 1987 ).

Locus of control.

The scale for this measures the respondent's perception of who is in control: him- or herself (internal control) or others, or fate (external control). The 17-item version of the scale was used ( Craig et al ., 1984 ). It has been shown to have good psychometric properties ( Haynes and Ayliffe, 1991 ).

Social support.

Based on an earlier analysis of the types and sources of social support ( House, 1981 ), the questionnaire asked how much social support the respondent would expect to receive from the spouse, relatives, and friends in case of a serious problem. The response options were (1) none at all, (2) a little, (3) average, (4) rather a lot, (5) a lot and (6) would not ask for help, or accept it. Similar questions have been used before in Finland ( Vahtera, 1993 ).

Laterality.

In line with earlier research ( Dellatolas et al ., 1990 ), laterality (handedness) was assessed by asking the preferred hand used for throwing, playing ball games and using a cooking pan, shaving or applying make-up, brushing teeth, slicing bread, hammering, turning a screwdriver, eating, combing hair, and writing. The answering options were ‘right hand always’, ‘right hand more often’, ‘both’, ‘left hand often’, and ‘left hand always’.

Social desirability.

This refers to the respondent's tendency to deceive in order to create a good impression. To measure it, three items from the Personality Diagnostic Questionnaire were used ( Hyler et al ., 1990 ).

Statistical analysis

Logistic regression was used to model relationships between alcohol dependence and suspected risk factors. First, all the risk factors were entered into the model as continuous variables whenever possible. Table 1 lists the measures that were used to evaluate risk factors possibly involved in the development of alcohol dependence; in addition to these 11 risk factors, age and social desirability were included in the full model. Variables not significantly associating with the diagnosis of alcohol dependence were removed. After this, interactions were studied. Finally, the model was re-parameterized to describe interactions. The strength of associations was summarized as odds ratios (OR). OR approximates the risk ratio when the prevalence of the disease is low. To calculate ORs, potential risk factor variables were dichotomized. The cut-off points were based on either natural categories (e.g. parental alcohol problems vs no parental alcohol problems), the population prevalence (e.g. the prevalence of left-handedness was set at 13.5%), or on the 67th percentile point of the total population sample in the case of continuous variables, so that the group consisting of the approximately one-third of the cases with the highest values represents those that might belong to the high-risk part of the distribution (see Table 1 for cut-off points). Because of a few missing cases and rounding the cut-off points to integers, the proportion of cases in the higher category is not always exactly 33%. Adjusted ORs and their 95% confidence intervals (95% CI), were calculated from the regression coefficients and their SEMs from the logistic models. Altogether, 3.7% of the responses were missing. Missing responses were replaced by the value for the reference category for the variable in question. Because of an emphasis on marital therapy in the hospital, women were over- represented in the clinical sample, and men and women were therefore analysed separately.

Among both men and women, significant positive associations were found between alcohol dependence and parental alcohol problems, with trait anxiety, high antisocial behaviour, high impulsivity, and high monotony avoidance (Table 1 ). Likewise, significant negative associations were found between alcohol dependence and high facial flushing score, high social support and becoming highly stimulated by alcohol intoxication (Table 1 ). There was no association between dependence and left-handedness. High external locus of control associated negatively with dependence was found only among men (Table 1 ).

Logistic regression analyses with continuous independent variables showed that not all bivariate associations remained significant in multivariate models and that there were several interactions between the significant independent variables. Therefore, the models were re-parameterized to describe interactions. For example, the trait anxiety–parental alcohol problems interaction was represented by the three new (0 or 1) dummy variables ‘high trait anxiety, parental alcohol problems', ‘high trait anxiety, no parental alcohol problems', and ‘low trait anxiety, parental alcohol problems' leaving ‘low trait anxiety, no parental alcohol problems' as the reference cateogry.

In the final logistic model for men (Table 2 ), both high trait anxiety and parental alcohol problems associated positively with alcohol dependence and interacted strongly. The OR for dependence was from two to three times higher among men with both high trait anxiety and parental alcohol problems than among men with only one of these two risk factors. Negative associations were found for high facial flushing, high stimulation when intoxicated by alcohol and high social support (Table 2 ).

In the final model for women (Table 3 ), high antisocial behaviour, high impulsivity, and high externality (measured on the locus of control scale) associated positively with alcohol dependence. Moreover, women with both high trait anxiety and low social support were more often dependent on alcohol than women with either low trait anxiety or high social support. The occurrence of alcohol dependence was increased among women with low facial flushing if they also had a history of parental alcohol problems. Decreased occurrence was found among women with high facial flushing irrespective of alcohol problems among their parents, and also among women who had reported high stimulation when intoxicated by alcohol (Table 3 ).

Among men, increased occurrence of alcohol dependence was related to both high trait anxiety and parental alcohol problems. Decreased occurrence was related to high facial flushing, high stimulation when intoxicated by alcohol, and high social support. Among women, increased occurrence was related to high antisocial behaviour, high impulsivity, and high externality, to the joint presence of high trait anxiety and low social support, and to the joint presence of low facial flushing and parental alcohol problems. Decreased occurrence was related to high facial flushing and to high stimulation when intoxicated by alcohol. Some of the factors studied, for example facial flushing, can be seen as preventive factors, or contrariwise, the lack of the preventive category can be seen as a risk factor.

Approximately one-half of the consecutive hospital patients did not take part in the study. This was mainly due to the fact that patients who were judged to be too confused, chaotic or tired were not asked to take part. Thus, the present patient series may represent the less severe half of in-patients with alcohol dependence. Although this might weaken the observed associations, the statistical analysis based on categorized variables should be relatively insensitive to this possible bias.

The present study was based on self-reports. These may be inaccurate. However, scales were applied that have been found earlier to have good psychometric validity and good reliability. The tendency to give socially desirable answers was controlled for in the multivariate analyses. Responses to some scales in this study might have been sensitive to possible influence of recent withdrawal symptoms. To control for this, alcohol dependence cases who met the withdrawal criterion were compared with those who did not fulfil this criterion. There were no differences between these groups in the scores of trait anxiety, antisocial behaviour, impulsivity, or monotony avoidance scales. There is no reason to suspect any serious bias in the present data. Any lack of reliability in the scales applied is likely to decrease correlations, and the actual associations are therefore probably stronger than those observed. In contrast to many earlier studies that have combined alcohol dependence and alcohol abuse into the category of alcoholism, the outcome variable in the present study was alcohol dependence. The latter diagnosis has been found to be reliable, whereas alcohol abuse has not ( Schuckit et al ., 1994 ). The reliability of the diagnosis of alcoholism in earlier studies and its correspondence to the present ICD-10 and DSM-IV criteria may vary and undermine comparability between studies.

Trait anxiety is a relatively stable behavioural predisposition, thought to reflect the degree of arousal brought about by adverse stimuli ( Andrews, 1991 ), and has been found to be determined partly by environmental and partly by genetic factors ( Gustavsson et al ., 1996 ). Strong correlations have been found between trait anxiety and autonomic nervous system activity, both at rest and under stress ( Zahn et al ., 1991 ). The present results support the view that trait anxiety is an important risk factor for alcohol dependence. This view is also supported by observational and experimental studies. In the rat, anti-anxiety actions of ethanol seem to be important reinforcers of voluntary ethanol consumption ( Möller et al ., 1997 ). Men with strong cardiovascular reactions to signalled shock have been found to drink more alcoholic drinks when asked to rate the flavour of these drinks, and to have more frequent histories of alcoholism than control men ( Pihl et al ., 1994 ). Cross-sectionally, high trait anxiety has been found to associate with susceptibility to heavy alcohol use among adolescents ( Colder and Chassin, 1993 ) and with craving for alcohol among alcoholics ( McCusker and Brown, 1991 ). Longitudinally, trait anxiety has been found to predict alcohol dependence ( Heath et al ., 1997 ) and anxiety disorder has been found to be a risk factor for alcohol dependence ( Kushner et al ., 1999 ).

Part of the association between high trait anxiety and alcohol dependence could result from an opposite causal pathway. Heavy alcohol use can induce anxiety in the short term ( Kushner et al ., 1990 ; Brown et al ., 1991 ; Schuckit and Hesselbrock, 1994 ). However, this is unlikely to materially influence the results for several reasons. First, the questionnaires were filled in later than the first week of hospital treatment. Secondly, the instruction to the trait anxiety questions stresses that the respondent should think about how he or she has generally felt in the past, not about the present state. Thirdly, trait anxiety scores did not differ between the alcohol dependence cases who met the diagnostic withdrawal symptom criterion and those who did not fulfil this criterion. Earlier, trait anxiety measured at admission to withdrawal treatment has been found to correlate closely with that measured 4 weeks later ( r = 0.91) or 8 weeks later ( r = 0.76) ( Ward and Hemsley, 1982 ). The present results are in line with a Swedish cohort study of almost 50 000 male conscripts, which found that both poor emotional control based on standardized tests and self-report of often feeling anxious predicted subsequent higher incidence of admission to psychiatric in-patient care because of alcoholism over a 15-year follow-up period ( Andréasson et al ., 1993 ).

In line with a host of earlier studies, parental alcohol problems were clearly related to an increased occurrence of alcohol dependence ( Dawson et al ., 1992 ; Kendler et al ., 1995 ; Kranzler et al ., 1997 ). Among men, there was a strong interaction between high trait anxiety and parental alcohol problems. Compared with men with low trait anxiety and no parental alcohol problems, the men with either one of these risk factors had an 11–13-fold OR for alcohol dependence, whereas men with both these risk factors had a 28-fold OR. The strong interaction between high trait anxiety and parental alcohol problems may go unnoticed if the emphasis is on the typology of alcoholics. For example, the typology of Cloninger ( Cloninger et al ., 1988 ; Sigvardsson et al ., 1996 ) divides alcoholics into two types. The type 2 alcoholic has early onset, familial alcohol problems, low reward dependence, low harm avoidance, and high novelty seeking. The type 1 alcoholic exhibits late onset, high reward dependence, high harm avoidance, and low novelty seeking. Harm avoidance and reward dependence correlate with trait anxiety and some of their features are similar to those of trait anxiety. Moreover, type 1 alcoholics are postulated to drink to relieve anxiety ( Sigvardsson et al ., 1996 ). In terms of this typology, the cases with high trait anxiety might fall into the type 1 category and those with parental alcohol problems into the type 2 category. There would, however, be no clear place for the cases who have both these risk factors.

Antisocial personality styles, central in the vulnerability-severity typology of Babor et al . (1992) were examined by the monotony avoidance, impulsiveness, and antisocial behaviour scales. Finnish alcoholic offenders with antisocial personality disorder have earlier been found to differ significantly from normal controls with respect to these three scales ( Virkkunen et al ., 1994 ). Also in the present study, cases with alcohol dependence had higher scores of monotony avoidance, impulsiveness, and antisocial behaviour than controls in bivariate analysis. In multivariate analysis, however, only impulsivity and antisocial behaviour in women remained significant, although the distributions of these three variables included high scores also among men, and alcohol-dependent men had significantly higher mean scores for both antisocial behaviour and impulsivity than the control men (data not shown). High antisocial behaviour implies early conduct problems, since 13 of the 20 scale items pertain to childhood and adolescence. Thus, early antisocial problems seem to be a risk factor for alcohol dependence in women. Surprisingly, this was not true for men. One possible explanation is that, among men, parental alcohol problems may be, in addition to being an indicator of genetic susceptibility to alcohol dependence, also an indicator of antisocial behaviour tendencies. The alcoholic parent is not likely to be deeply involved with bringing up children and this might bring about difficulties in learning social behaviour patterns, especially among boys. This is supported by both epidemiological follow-up studies and animal experiments. In adolescents, parental substance abuse disorder predicts a decrease in family attachment and increases in both life events and drug use ( Hoffman and Su, 1998 ). A 33-year follow-up study of adolescent boys found that, after parental alcoholism was controlled for, unstable relationship with the father and low familial cohesion no longer explained alcohol dependence ( Vaillant, 1984 ). Experimental studies in the rhesus monkey suggest that peer rearing, a model for human parental neglect, is related to impaired social functioning, disruptive social behaviours, excessive alcohol intake and low serotonin turnover rate, patterns similar to those in early onset alcoholism among humans ( Higley et al ., 1996 ; Heinz et al ., 1998 ). The present data are also consistent with this view, since alcohol-dependent men who reported parental alcohol problems had significantly higher mean scores for antisocial behaviour than the dependent men with no parental alcohol problems (data not shown).

High external control of behaviour was a risk factor for alcohol dependence in women. Subjects with high external control think that their behaviour is determined mainly by chance or by other people. This implies lack of both self-control, self-efficacy and personal autonomy. Earlier, high external control scores in adolescence have been found to predict heavy alcohol use in young adulthood for both males and females ( Steele et al ., 1995 ).

Several factors being studied were found to associate negatively with alcohol dependence, suggesting a preventive influence. Social support was important among both men and women. Among women, a buffering effect against high trait anxiety was suggested by the interaction observed. High stimulation when intoxicated by alcohol was related to a decreased occurrence of alcohol dependence both among men and women. This agrees with findings implying that low responsivity to alcohol (low level of intoxication after ingesting 0.75 to 1.1 ml/kg of ethanol) increases the risk of alcohol dependence ( Schuckit and Smith, 1996 ; Volavka et al ., 1996 ). High scores of facial flushing also showed a negative association with alcohol dependence. This is a new finding in a White population and interesting, because alcohol-induced facial flushing is relatively weak or absent among White subjects, in contrast to Oriental subjects ( Ward et al ., 1994 ). However, unpleasant reactions to alcohol at least occasionally have been reported by approximately one-quarter of the men and one-half of the women among subjects of European descent ( Whitfield and Martin, 1996 ). These reactions are not solely explained by the deficiency of aldehyde dehydrogenase 2 causing the alcohol flush reaction ( Whitfield and Martin, 1996 ). Metabolic, allergic or other immunologic causes may play a role. The present results suggest that unpleasant reactions to alcohol also have some preventive effect among White subjects.

Left-handedness has earlier been found to be more common among problem drinkers and alcoholics, than among healthy control subjects ( Bakan, 1973 ; McNamara et al ., 1994 ). These studies have been based on small samples. The present study did not find any significant association between left-handedness and alcohol dependence. There are two possible explanations. Either left-handedness is not a risk factor for alcohol dependence, or the effect is a minor one. The present results indicate that a larger than twofold increase in OR can be excluded with 95% confidence. If the suspected risk factor is a weak one, then larger samples yielding risk estimates with high precision are needed to show more definitely that there is no difference.

To sum up, the present results stress the multifactorial nature of the aetiology of alcohol dependence, differences between men and women and interactions between several risk factors. The findings suggest that parental alcohol problems and high trait anxiety strongly increase the risk of alcohol dependence. Moreover, high antisocial behaviour, impulsivity, and externality are important among women. Risk factors that seem to decrease risk include facial flushing, high stimulation when intoxicated by alcohol and high social support. Follow-up studies are needed to examine more closely the multitude of risk factors for alcohol dependence.

Risk factors for ICD-10 alcohol dependence, crude odds ratios (OR), and their 95% confidence interval (95% CI)

Risk factors for ICD-10 alcohol dependence by multiple logistic regression, adjusted odds ratios (OR), and their 95% confidence interval (95% CI) in 117 male cases and 248 male controls

Risk factors for ICD-10 alcohol dependence by multiple logistic regression, adjusted odds ratios (OR), and their 95% confidence interval (95% CI) in 188 female cases and 300 female controls

Address for correspondence: Järvenpää Addiction Hospital, FIN-04480 Haarajoki, Finland.

This research was supported by the Järvenpää Addiction Hospital (of the A-Clinic Foundation), the Department of Mental Health and Alcohol Research at the National Public Health Institute (KTL) in Finland, and partly with a grant from the Yrjö Jahnsson Foundation.

American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders , 3rd edn, revised. American Psychiatric Association, Washington, DC.

Andréasson, S., Allebeck, P. and Brandt, L. ( 1993 ) Predictors of alcoholism in young Swedish men. American Journal of Public Health 83 , 845 –850.

Andrews, G. ( 1991 ) Anxiety, personality and anxiety disorders. International Review of Psychiatry 3 , 293 –302.

Babor, T. F., Hofmann, M., Delboca, F. K., Hesselbrock, M., Meyer, R. E., Dolinsky, Z. S. and Rounsaville, B. ( 1992 ) Types of alcoholics. I. Evidence for empirically derived typology based on indicators of vulnerability and severity. Archives of General Psychiatry 49 , 599 –608.

Bakan, P. ( 1973 ) Left-handedness and alcoholism. Perceptual and Motor Skills 36 , 514 .

Bech, P., Malt, U. F., Dencker, S. J., Ahlfors, U. G., Elgen, K., Lewander, T., Lundell, A., Simpson, G. M. and Lingjærde, O. (eds) (1993) Scales for assessment of diagnosis and severity of mental disorders. Acta Psychiatria Scandinavica 87 , 4 –28.

Brook, J. S., Whiteman, M., Cohen, P., Shapiro, J. and Balka, E. ( 1995 ) Longitudinally predicting late adolescent and young adult drug use: childhood and adolescent precursors. Journal of the American Academy of Child and Adolescent Psychiatry 34 , 1230 –1238.

Brown, S. A., Irwin, M. and Schuckit, M. A. ( 1991 ) Changes in anxiety among abstinent male alcoholics. Journal of Studies on Alcohol 52 , 55 –61.

Cadoret, R. J., Yates, W. R., Troughton, E., Woodworth, G. and Stewart, M. A. ( 1995 ) Adoption study demonstrating two genetic pathways to drug abuse. Archives of General Psychiatry 52 , 42 –52.

Caetano, R. and Tam, T. W. ( 1995 ) Prevalence and correlates of DSM-IV and ICD-10 alcohol dependence: 1990 US National Alcohol Survey. Alcohol and Alcoholism 30 , 177 –186.

Cloninger, C. R., Sigvardsson, S. and Bohman, M. ( 1988 ) Childhood personality predicts alcohol abuse in young adults. Alcoholism: Clinical and Experimental Research 12 , 494 –505.

Colder, C. R. and Chassin, L. ( 1993 ) The stress and negative affect model of adolescent alcohol use and the moderating effects of behavioral undercontrol. Journal of Studies on Alcohol 54 , 326 –333.

Craig, A. R., Franklin, A. and Andrews, G. ( 1984 ) A scale to measure locus of control of behaviour. British Journal of Medical Psychology 57 , 173 –180.

Dawson, D. A., Harford, T. C. and Grant, B. F. ( 1992 ) Family history as a predictor of alcohol dependence. Alcoholism: Clinical and Experimental Research 16 , 572 –575.

Dellatolas, G., Annesi, I., Jallon, P., Chavance, M. and Lellouch, J. ( 1990 ) An epidemiological reconsideration of the Geschwind– Galaburda theory of cerebral lateralization. Archives of Neurology 47 , 778 –782.

Gordis, E. ( 1996 ) Alcohol research. At the cutting edge. Archives of General Psychiatry 53 , 199 –201.

Gustavsson, J. P., Pedersen, N. L., Åsberg, M. and Sshalling, D. ( 1996 ) Origins of individual differences in anxiety proneness: a twin/adoption study of the anxiety-related scales from the Karolinska Scales of Personality (KSP). Acta Psychiatria Scandinavica 93 , 460 –469.

Haynes, P. and Ayliffe, G. ( 1991 ) Locus of control of behaviour: is high externality associated with substance misuse? British Journal of Addiction 86 , 1111 –1117.

Heath, A. C., Bucholz, K. K., Madden, P. A. F. et al . ( 1997 ) Genetic and environmental contributions to alcohol dependence risk in a national twin sample: consistency of findings in women and men. Psychological Medicine 27 , 1381 –1396.

Heinz, A., Higley, J. D., Gorey, J. G., Saunders, R. C., Jones, D. W., Hommer, D., Zajicek, K., Suomi, S. J., Lesch, K.-P., Weinberger, D. R. and Linnoila, M. ( 1998 ) In vivo association between alcohol intoxication, aggression, and serotonin transporter availability in nonhuman primates. American Journal of Psychiatry 155 , 1023 –1028.

Higley, J. D., Suomi, S. J. and Linnoila, M. ( 1996 ) A nonhuman primate model of type II alcoholism? Part 2. Diminished social competence and excessive aggression correlate with low cerebrospinal fluid 5-hydroxyindoleacetic acid concentrations. Alcoholism: Clinical and Experimental Research 20 , 643 –650.

Hoffman, J. P. and Su, S. ( 1998 ) Parental substance use disorder, mediating variables and adolescent drug use: a non-recursive model. Addiction 93 , 1351 –1364.

House, J. S. (1981) Work Stress and Social Support . Addison-Wesley, Reading, MA.

Hyler, S., Skodol, A., Kellman, D., Oldham, J. and Rosnick, L. ( 1990 ) Validity of the Personality Diagnostic Questionnaire — Revised: comparison with two structured interviews. American Journal of Psychiatry 147 , 1043 –1048.

Kendler, K. S., Walters, E. E., Neale, M. C., Kessler, R. C., Heath, A. C. and Eaves, L. J. ( 1995 ) The structure of the genetic and environmental risk factors for six major psychiatric disorders in women. Archives of General Psychiatry 52 , 374 –383.

Knorring von, L., Knorring von, A-L., Smigan, L., Lindberg, U. and Edholm, M. ( 1987 ) Personality traits in subtypes of alcoholics. Journal of Studies on Alcohol 48 , 523 –527.

Kranzler, H. R., Babor, T. F. and Moore, P. (1997) Alcohol use disorders. In Psychiatry , Tasman, A., Kay, J., Lieberman, J. A. eds, pp. 755–778. W. B. Saunders, Philadelphia, PA.

Kushner, M. G., Sher, K. J. and Beitman, B. D. ( 1990 ) The relation between alcohol problems and the anxiety disorders. American Journal of Psychiatry 147 , 685 –695.

Kushner, M. G., Sher, K. J., Erickson, K. J. and Darin, J. ( 1999 ) Prospective analysis of the relation between DSM-III anxiety disorders and alcohol use disorders. American Journal of Psychiatry 156 , 723 –732.

Lewis, C. E. and Bucholz, K. K. ( 1991 ) Alcoholism, antisocial behaviour and family history. British Journal of Addiction 86 , 177 –194.

Martin, C. S., Earleywine, M., Musty, R. E., Perrine, M. W. and Swift, R. M. ( 1993 ) Development and validation of the Biphasic Alcohol Effects Scale. Alcoholism: Clinical and Experimental Research 17 , 140 –146.

McCord, W. and McCord, J. (1960) Origins of Alcoholism . Stanford University Press, Stanford, CA.

McCusker, C. G. and Brown, K. ( 1991 ) The cue-responsivity phenomenon in dependent drinkers: ‘personality’ vulnerability and anxiety as intervening variables. British Journal of Addiction 86 , 905 –912.

McNamara, P., Blum, D., O'Quin, K. and Schachter, S. ( 1994 ) Markers of cerebral lateralization and alcoholism. Perceptual and Motor Skills 79 , 1435 –1440.

Merikangas, K. R., Risch, N. J. and Weissman, M. M. ( 1994 ) Comorbidity and co-transmission of alcoholism, anxiety and depression. Psychological Medicine 24 , 69 –80.

Miller, L. ( 1991 ) Predicting relapse and recovery in alcoholism and addiction: neuropsychology, personality, and cognitive style. Journal of Substance Abuse Treatment 8 , 277 –291.

Möller, C., Wiklund, L., Thorsell, A., Hyytiä, P. and Heilig, M. ( 1997 ) Decreased measures of experimental anxiety in rats bred for high alcohol preference. Alcoholism: Clinical and Experimental Research 21 , 656 –660.

Ohannessian, C. M. and Hesselbrock, V. M. ( 1993 ) The influence of perceived social support on the relationship between family history of alcoholism and drinking behaviors. Addiction 88 , 1651 –1658.

Pihl, R. O., Giancola, P. R. and Peterson, J. B. ( 1994 ) Cardiovascular reactivity as a predictor of alcohol consumption in a taste test situation. Journal of Clinical Psychology 50 , 280 –286.

Pohorecky, L. A. ( 1991 ) Stress and alcohol interaction: an update of human research. Alcoholism: Clinical and Experimental Research 15 , 438 –459.

Poikolainen, K. ( 1997 ) Risk factors for alcohol dependence: a questionnaire survey. Alcoholism: Clinical and Experimental Research 21 , 957 –961.

Robins, L. N., Bates, W. N. and O'Neal, P. (1962) Adult drinking patterns of former problem children. In Society, Culture and Drinking Pattern s, Pitman, D. J. P. and Snyder, C. R., eds, pp. 395–412. Wiley, New York.

Schuckit, M. A. ( 1994 ) Low level of response to alcohol as a predictor of future alcoholism. American Journal of Psychiatry 151 , 184 –189.

Schuckit, M. A. and Hesselbrock, V. ( 1994 ) Alcohol dependence and anxiety disorders: what is the relationship? American Journal of Psychiatry 151 , 1723 –1734.

Schuckit, M. A. and Smith, T. L. ( 1996 ) An 8-year follow-up of 450 sons of alcoholic and control subjects. Archives of General Psychiatry 53 , 202 –210.

Schuckit, M. A., Hesselbrock, V., Tipp, J., Anthenelli, R., Bucholz, K. and Radziminski, S. ( 1994 ) A comparison of DSM-III-R, DSM-IV and ICD-10 substance use disorders diagnoses in 1922 men and women subjects in the COGA study. Addiction 89 , 1629 –1638.

Sigvardsson, S., Bohman, M. and Cloninger, R. ( 1996 ) Replication of the Stockholm adoption study of alcoholism: confirmatory cross-fostering analysis. Archives of General Psychiatry 53 , 681 –687.

Spak, L., Spak, F. and Allebeck, P. ( 1997 ) Factors in childhood and youth predicting alcohol dependence and abuse in Swedish women: findings from a general population study. Alcohol and Alcoholism 32 , 267 –274.

Spielberger, C. D., Gorsuch, R. L. and Lushene, R. E. (1970) STAI Manual for the State-trait Anxiety Inventory . Consulting Psychologists Press, Palo Alto, CA.

Steele, R. G., Forehand, R., Armistead, L. and Brody, G. ( 1995 ) Predicting alcohol and drug use in early adulthood: the role of internalizing and externalizing behavior problems in early adolescence. American Journal of Orthopsychiatry 65 , 380 –388.

Vahtera, J. ( 1993 ) Työn hallinta, sosiaalinen tuki ja terveys. Työ ja ihminen 7 , Suppl. 1 .

Vaillant, G. E. (1984) The contribution of prospective studies to the understanding of etiologic factors in alcoholism. In Research Advances in Alcohol and Drug Problems , Smart, R. G., Cappell, H. D., Glaser, F. B., Israel, Y., Kalant, H., Popham, R. E., Schmidt, W., Sellers, E. M. eds., pp. 265–289. Addiction Research Foundation and University of Toronto, Toronto.

Vaillant, G. E. and Milofsky, E. S. ( 1982 ) The etiology of alcoholism. American Psychologist 37 , 494 –503.

Virkkunen, M., Kallio, E., Rawlings, R., Tokola, R., Poland, R. E., Guidotti, A., Nemeroff, C., Bissette, G., Kalogeras, K., Karonen, S-L. and Linnoila, M. ( 1994 ) Personality profiles and state aggressiveness in Finnish alcoholic, violent offenders, fire setters, and healthy volunteers. Archives of General Psychiatry 51 , 28 –33.

Volavka, J., Czobor, P., Goodwin, D. W., Gabrielli, W. F. Jr, Penick, E. C., Mednick, S. A., Jensen, P., Knop, J. and Schulsinger, F. ( 1996 ) The electroencephalogram after alcohol administration in high-risk men and the development of alcohol use disorders 10 years later. Archives of General Psychiatry 53 , 258 –263.

Ward, E. S. and Hemsley, D. R. ( 1982 ) The stability of personality measures in drug abusers during withdrawal. International Journal of Addiction 17 , 575 –583.

Ward, R. J., McPherson, A. J. S., Chow, C., Ealing, J., Sherman, D. I. N., Yoshida, A. and Peters, T. J. ( 1994 ) Identification and characterization of alcohol-induced flushing in Caucasian subjects. Alcohol and Alcoholism 29 , 433 –438.

Whitfield, J. B. and Martin, N. G. ( 1996 ) Alcohol reactions in subjects of European descent: effects on alcohol use and on physical and psychomotor responses to alcohol. Alcoholism: Clinical and Experimental Research 20 , 81 –87.

Whitfield, J. B., Nightingale, B. N., Bucholz, K. K., Madden, P. A. F., Heath, A. C. and Martin, N. G. ( 1998 ) ADH genotypes and alcohol use and dependence in Europeans. Alcoholism: Clinical and Experimental Research 22 , 1463 –1469.

World Health Organization (1992) International Classification of Diseases , 10th edn. World Health Organization, Geneva.

Worobec, T. G., Turner, W. M., O'Farrell, T. J., Cutter, H. S., Bayog, R. D. and Tsuand, M. T. ( 1990 ) Alcohol use by alcoholics with and without a history of parental alcoholism. Alcoholism: Clinical and Experimental Research 14 , 887 –892.

Yoshino, A. and Kato, M. ( 1995 ) Influence of social desirability response set on self-report for assessing the outcome of treated alcoholics. Alcoholism: Clinical and Experimental Research 19 , 1517 –1519.

Zahn, T. P., Nurnberger, J. I., Berrettini, W. H. and Robinson, T. N. ( 1991 ) Concordance between anxiety and autonomic nervous system activity in subjects at genetic risk for affective disorder. Psychiatry Research 36 , 99 –110.

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Application of transtheoretical model in management of individual with alcohol dependence: A case study

Affiliation.

• 1 Department of Clinical Psychology, Mental Health Institute, SCB MCH, Cuttack, Odisha, India.
• PMID: 31879462
• PMCID: PMC6929224
• DOI: 10.4103/ipj.ipj_50_17

Studies have focused on the efficacy of transtheoretical model in the management of substance dependence, but not much have focused on the changes with respect to the patient's mood, life skills, and interpersonal relationship issues that take place during the therapy. The present study explores a case by using motivational interviewing and relapse prevention strategies to qualitatively record the applicability of the transtheoretical model in terms of readiness to change, action taken, relationship conflicts, assertiveness, and depression in an individual with alcohol dependence. The intervention was carried out over 3 months for ten sessions followed by follow-up for 8 months. The results indicated improvement in the patient in the dimensions of level of action taken for increasing abstinence period, decreasing the level of depression, enhancing readiness to change, and improving assertiveness and improvement in marital adjustment with spouse, which were observed and reported during the post follow-up sessions.

Keywords: Alcohol dependence; case study; motivational interviewing; transtheoretical model.

Copyright: © 2019 Industrial Psychiatry Journal.

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Management of Alcohol Dependence Syndrome - A single Case Study

2023, International Journal of Scientific Research

Background: Alcohol addiction is a complex and dynamic process. Prolonged excessive alcohol consumption causes neuroadaptive changes in the brain's reward and stress systems. It has been directly linked to various social, economic, and health problems. : The case Aims & Objectives study aims to reduce the symptoms of person diagnosed with alcohol dependence syndrome. The attempt has been to bring out changes in motivation level and to enhance coping skills. The client was assessed, diagnosed, and a treatment plan was developed. Methodology: Implemented treatment consisted of motivational enhancement therapy, components of cognitive behavioural therapy, refusal skills, relaxation therapy, anger management and sleep hygiene. The Mini Mental Status Examination, Alcohol Use Disorders Identication Test, Alcohol Craving Questionnaire, SACK's sentence completion test & Beck Depression Inventory were used to access the severity of the symptoms. Result & Conclusion: Results indicated a signicant decline in the alcohol dependence symptoms over the course of the treatment.

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Rivista di psichiatria

Daniela Fiorentino

The development of a treatment for alcohol use disorder (AUD) is a crucial and complex moment. Indeed, the information gathered by a team of professionals (physicians, psychologists and social workers) (bio-psycho-social model of AUD) interact to choose the most appropriate cure. As for AUD psychological treatment, it is of considerable importance to avoid clinical treatments leading to drop-out for improving the patients quality of life. Psychoanalytic and behavioral techniques were early utilized as psychological treatment of AUD, however, evidence-based approaches as motivational interviewing (MI) and cognitive behavioral therapy (CBT) are recently used in AUD. In this work we review the more effective and appropriate AUD psychological treatments.

Effectiveness of Cognitive Behavioral Therapy in Treatment of Patients with Alcohol Dependence

bwalya bwembya

Global harmful alcohol use accounted for 5.9% of deaths, 5.1% disease burden in 2012 [43]. In Zambia, 15.6% drinks, where heavy consumption stands at 43.7%. The aim of this study was to investigate the effect of CBT in treatment of patients (pts) with alcohol dependence. The first specific objective to determine the differences in treatment outcome between CBT and non-CBT patients with alcohol dependence, was analyzed by MANOVA. The second objective to evaluate the effect of demographic factors on CBT treatment outcome in patients with alcohol dependence was analyzed by general regression analysis. The third objective to find out whether CBT had different effect on some alcohol dependence variables and not others was analyzed by MANOVA. The study design was randomized controlled trial (RCT) having intervention and control groups. Intervention group received [8] CBT sessions on a weekly basis whereas control group received treatment as usual. All patients met the DSM V and AUDIT diagnostic criteria for alcohol dependence. Using CI 95%, 0.05 alpha and power of 1-beta (80%), the sample size was calculated at 50 and was divided into two groups. Patients were recruitment by systematic sampling every third patient. Probability sampling was used to assign patients to intervention or control group. MANOVA to determine the differences in treatment outcome between CBT and non-CBT patients with alcohol dependence was not statically significant in pretest, P > 0.05 = 0.23, but the results showed statistical significance in post test data, P < 0.05 = 0.01. Hence, the alternative hypothesis was not rejected. The general linear regression model for the second object demonstrated that demographic factors were not statistically significant neither in CBT group data nor in the control group data, that is equal to 0.29, P > 0.05 and 0.38, P > 0.05. Furthermore, MANOVA analysis showed inferential statistical significance in all the alcohol dependence variables with the overall sig. 0.001, P < 0.05. Each of the variables was represented by statistical significance of 0.001. Thus, CBT presented statistical significance on each and every variable of alcohol dependence. Therefore, CBT is more effective in treatment of patients with alcohol dependence than standard treatment.

Indo Global Journal of Pharmaceutical Sciences

Priya Mishra

American Journal of Life Sciences

Amitabh Saha

Psychology and Education: A Multidisciplinary Journal

Psychology and Education , Jonathan Rey A. Indon

The researcher sought to study the level of depression, anxiety and stress of individuals working in construction industry as well as its correlation to alcohol dependence. The data was gathered using questionnaires to get a picture of the beliefs and or behaviors of the sample. The chosen participants in the research were selected to be the representative of all the individuals that the researcher wishes to know about the population, then correlating them to discover the relationships among variables. Major findings were revealed: There was a significant relationship between depression and alcohol dependence, anxiety and alcohol dependence and stress and alcohol dependence. In addition, among the 181 respondents in terms of depression from Mild to Extremely Severe 66.30% experienced depressive symptoms one way or another. In terms of anxiety, Extremely Severe got the highest percentage value, 38.67%. As to stress Normal, the highest is 46.41% and finally, for alcohol dependence, 55.80% of them are in Low Level of dependency.

Indian Journal of Psychological Medicine

Pratima Murthy

BHASWAB GOSWAMI

Background: Relapse prevention therapy propounded by Marlatt and Gordon is found to be effective in the process of prevention or delaying of relapse by persons with Alcohol use disorder. It is based on the Cognitive Behavioural approach and employs strategies to identify high risk situations. Aim: The study aims to explore the efficacy of Relapse prevention strategies in maintaining abstinence. Methods: The study is based on a single case study design done inside the Department of Deaddiction, Lokopriyo Gopinath Bordoloi Regional Institute of Mental Health, Tezpur. The case in this context is an individual diagnosed with Alcohol Dependence Syndrome as per the International Classification of Diseases-10 (ICD 10). A qualitativeassessment was done to understand the psychosocial background of the client besides exploring the risk factors for relapse (immediate determinants and covert antecedents). Following assessment Psychosocial interventions were provided inthe form of relapse prevention therapy sessions at the individual level and family Psychoeducation. Result: During the followups of 3 months, 6 months and 1 year after the Psychosocial treatment the individual was found to be abstinent with an improvement in work functioning. Conclusion: Relapse prevention therapy techniques have been effective in helping the client maintain abstinence. The client was also able to develop alternative ways of coping stressful situations.

Open Journal of Psychiatry & Allied Sciences

Harikrishnan U, PhD

This case study is an attempt to assess the impact of psychiatric social work intervention in person with alcohol dependence. Psychiatric social work intervention (brief intervention) was provided to the client focusing on building motivation for change and strengthening commitment to change. It uses a single subject design and compares pre-and post-intervention baseline data with that following intervention. Semi-structured clinical and socio-demographic data sheet, family assessment proforma, and readiness to change questionnaires were administered to the client. The brief psychiatric social work intervention was provided to the client and family members. The attempt has been to bring out changes in motivation level and to enhance coping skill. After brief psychiatric social work intervention, knowledge regarding the illness was enhanced. The client motivation level was enhanced, family members have better understanding about client's illness, and interpersonal relationship has been improved.

Indian journal of psychiatry

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Robert’s story

Robert was living with an alcohol addiction and was homeless for over 25 years. He was well known in the local community and was identified as one of the top 100 A&E attendees at the Local General Hospital.

He drank all day every day until he would pass out and this was either in the town centre or just by the roadside. In addition, Robert was also incontinent and really struggled with any meaningful communication or positive decision making due to his alcohol usage. This often resulted in local services such as police, ambulance being called in to help. He had no independent living skills and was unable to function without alcohol.

In addition, and due to his lifestyle and presenting behaviours, Robert had a hostile relationship with his family and had become estranged from them for a long period of time.

Robert needed ongoing support and it was identified at the General Hospital that if he was to carry on “living” the way he currently was, then he wouldn’t survive another winter.

On the back of this, Robert was referred to Calico who organised a multi-disciplinary support package for him, which included support with housing as part of the Making Every Adult Matter programme.

After some initial challenges, Robert soon started to make some positive changes.

The intensive, multidisciplinary support package taught him new skills to support him to live independently, sustain his tenancy and make some positive lifestyle changes which in turn would improve his health and wellbeing.

This included providing daily visits in the morning to see Robert and to support him with some basic activities on a daily/weekly basis. This included getting up and dressed; support with shopping and taking to appointments; guidance to help make positive decisions around his associates; support about his benefits and managing his money. In addition, he was given critical support via accessing local groups such as RAMP (reduction and motivational programme) and Acorn (drugs and alcohol service), as well as 1 to 1 sessions with drugs workers and counsellors to address his alcohol addiction.

After six months Robert continued to do well and was leading a more positive lifestyle where he had greatly reduced his A&E attendance. He had significantly reduced his alcohol intake with long periods of abstinence and was now able to communicate and make positive decisions around his lifestyle.

Critically he had maintained his tenancy and continued to regularly attend local groups and other support for his alcohol addiction and had reconnected with some of his family members.

By being able to access these community resources and reduce his isolation he is now engaged in meaningful activities throughout the day and has been able to address some of his critical issues. A small but significant example is that Robert is now wearing his hearing aids which means that he can now interact and communicate more effectively.

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I Overcame My Alcohol Addiction by Learning Two Lessons

When I was 14 years old, I became aware that I wanted to feel the effects of alcohol. I had a few drinks at a friend's house when his parents weren't home and quickly felt relaxed, uninhibited, and fearless.

I was convinced that alcohol was the cure for what bothered me at that time, namely issues related to feelings of inferiority, alienation, irritability, and trauma.

Twenty years later, I was aware that I was dying of alcoholism and no longer wanted to feel the effects of alcohol, which included isolation, depression, hopelessness, and suicidal ideation.

I'll spare you the details from two decades of active alcoholism, but I will share that my dependency issues got progressively worse. They stole my joy and purpose. They eradicated my moral and ethical codes. They created mental anguish and compounded existing emotional turmoil.

They discouraged positive hygiene habits or any form of self-care. They cost me hundreds of dollars, or more, every month as I consumed many bottles of liquor a day. They lead to co-addictive issues with other harmful substances and unwholesome behaviors. They wrecked my body and severed any conscious contact I had with my soul or spirit. Ultimately, they eroded my human will to live.

There can be a lot of shame and stigmatization associated with addictions. This is the main reason those who suffer from substance use disorders do not seek help. However, we must become aware that alcoholism affects all types of people.

Alcoholism does not care if we are mothers and fathers, sons and daughters, uncles and aunts, educated or not, wealthy or not, employed or not, young or old, married or divorced, religious or secular. Alcoholism will victimize anyone it can at any time.

Fortunately, I found a group of recovered alcoholics and asked them for help. They freely shared their experience, strength, hope, and specific steps anyone can take to find recovery. I took their suggestions and I've been gratefully sober ever since, for 14 years.

In celebration of Alcohol Awareness Month in the U.S., I would like to share two key elements about the nature of alcoholism so those who need help can receive it without fear of embarrassment, rejection, or judgment, and they may be supported by people who can offer empathy, encouragement, and kindness.

These concepts come from more than a dozen years of personal and professional experience becoming aware of causes, conditions, traumas, and triggers that lead to alcoholism and similar dependency issues.

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Alcoholism is Not a Choice

Alcoholics do not drink because they want to. They drink because they feel they need to or have to. They drink to obliterate their consciousness. They wish to escape reality—not to feel anything, to zone out, check out, numb out.

They try to leave their body and disassociate from horrors within their mind. They want to forget the memories that plague them. They hope to obliterate racing thoughts, resentments, grudges, attachments, traumas, and disillusionments that create pain and suffering.

Alcohol simply provides a temporary respite from life as it is. It's a timeout from being alive. Most active alcoholics are unaware of how to deal with life in the present moment so they alter their mindset to deaden their senses which creates distance between their consciousness and the rest of the world.

Recovery is Possible

When an alcoholic becomes aware of why they drink, they can address real problems and find viable solutions. For example, suppose an alcoholic realizes they drink because they're sad or lonely, once the original causes of sadness or loneliness are identified. In that case, these feelings can be processed, healed, and transformed.

This exploratory and necessary type of experiential work can be done therapeutically through cognitive-behavioral modalities such as the Twelve Steps—spiritually through yogic principles and practices, and secularly via mindfulness exercises and evidence-based programs.

Each alcoholic will individually respond to various treatments that root out repressed emotions and feelings, unresolved mental issues, and distressing physical experiences that instigate drinking.

When an alcoholic remembers that drinking is but an outward behavior to avoid unprocessed inner struggles, solutions will be found, and lasting freedom, contentment, and peace will manifest.

If you are struggling with alcoholism, remember you are not alone. You can recover. You don't need to fight this battle by yourself. If you need help, ask for it.

Reach out to a trusted friend or community member. Find virtual or in-person therapy sessions. Attend a Twelve Step meeting or similar group with like-minded people who are also seeking recovery, healing, and transformation. In the U.S., call or text 988, and chat at 988lifeline.org . To get additional support for mental health concerns about alcoholism, visit FindSupport.gov .

Brian Hyman is a certified yoga and meditation teacher, recovery activist, and father. He's been sober since 2009 and has been teaching yoga at Cliffside Malibu since 2012.

Brian is the author of Recovery with Yoga: Supportive Practices for Transcending Addiction (Shambhala Publications/Penguin Random House). His courses on Insight Timer include "Recovery: Principles for a Purposeful Life" and "Emotional Sobriety: Finding Freedom, Harmony, and Peace in Recovery."

All views expressed in this article are the author's own.

Do you have a unique experience or personal story to share? See our Reader Submissions Guide and then email the My Turn team at [email protected] .

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About the writer

Brian Hyman is the author of Recovery with Yoga: Supportive Practices for Transcending Addiction (Shambhala Publications/Penguin Random House). His courses on Insight Timer include "Recovery: Principles for a Purposeful Life" and "Emotional Sobriety: Finding Freedom, Harmony, and Peace in Recovery." Brian is a certified yoga and meditation teacher, recovery activist, and father. He's been sober since 2009 and has been teaching yoga at Cliffside Malibu since 2012.

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A Deep Dive Into the Genetics of Alcohol Consumption

Exploration of 3 million records uncovers connections between gene variants governing alcohol use and many non-alcohol-related conditions.

• Joseph McClain - [email protected]

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A research group centered at the University of California San Diego School of Medicine has drilled deep into a dataset of over 3 million individuals compiled by the direct-to-consumer genetics company 23andMe, Inc., and found intriguing connections between genetic factors influencing alcohol consumption and their relationship with other disorders.

The study was recently published in the Lancet eBioMedicine .

Sandra Sanchez-Roige, Ph.D., corresponding author and associate professor at UC San Diego School of Medicine Department of Psychiatry, explained that the study used genetic data to broadly classify individuals as being European, Latin American and African American. Such classifications “are needed to avoid a statistical genetics pitfall called population stratification,” noted co-author Abraham A. Palmer, Ph.D., professor and vice chair for basic research in the psychiatry department.

The researchers analyzed genetic data from the 3 million 23andMe research participants, focusing on three specific little snippets of DNA known as single-nucleotide polymorphisms, or SNPs. Sanchez-Roige explained that variants, or alleles, of these particular SNPs are “protective” against a variety of alcohol behaviors, from excessive alcohol drinking to alcohol use disorder.

One of the alcohol-protective variants they considered is very rare: the most prevalent among the three alleles found in the study showed up in 232 individuals of the 2,619,939 European cohort, 29 of the 446,646 Latin American cohort and in 7 of the 146,776 African American cohort; others are much more common. These variants affect how the body metabolizes ethanol — the intoxicating chemical in alcoholic beverages.

“The people who have the minor allele variant of the SNP convert ethanol to acetaldehyde very rapidly. And that causes a lot of negative effects,” said Sanchez-Roige. She went on to say that the resulting nausea eclipses any pleasurable effects of alcohol — think of a bad hangover that sets in almost immediately.

“These variants are primarily associated with how much someone may consume alcohol,” she said. “And they also tend to prevent alcohol use disorder, because these variants are primarily associated with the quantity of alcohol someone may drink.”

Sanchez-Roige explained that the SNP variants’ influence on alcohol consumption are well researched, but her group took a “hypothesis-free” approach to the 23andMe dataset, which contains survey data on thousands of traits and behaviors. The researchers wanted to find out if the three SNP variants might have any other effects beyond alcohol consumption.

Sanchez-Roige and Palmer noted that their group has developed a 10-year partnership with 23andMe that has focused on numerous traits, especially those with relevance for addiction. This work is the basis of an academic collaboration through the 23andMe Research Program. 

They data-mined the analyses of DNA from saliva samples submitted by consenting 23andMe research participants, as well as the responses to the surveys of health and behavior available from the 23andMe database, and found a constellation of associations, not necessarily connected with alcohol. Individuals with the alcohol-protecting alleles had generally better health, including less chronic fatigue and needing less daily assistance with daily tasks.

{/exp:typographee}

DNA holds the key to many health conditions and behaviors. A group of researchers at University of California School of Medicine has probed a large database of 23andMe clients and found new associations between various health conditions and genetic variants that protect people from alcohol abuse. Photo credit: Gerald/Pixabay

But the paper notes individuals with the alcohol-protective alleles also had worse health outcomes in certain areas: more lifetime tobacco use, more emotional eating, more Graves’ disease and hyperthyroidism. Individuals with the alcohol-protective alleles also reported totally unexpected differences, such as more malaria, more myopia and several cancers, particularly more skin cancer and lung cancer, and more migraine with aura. 

Sanchez-Roige acknowledged that there is a chicken-and-egg aspect to their findings. For example: Cardiovascular disease is just one of a number of maladies known to be associated with alcohol consumption. “So is alcohol consumption leading to these conditions?” she asks. Palmer finishes the thought: “Or do these genetic differences influence traits like malaria and skin cancer in a manner that is independent of alcohol consumption?”

Sanchez-Roige said that such broad, hypothesis-free studies are only possible if researchers have access to very large sets of data. Many datasets, including the one used in the study, rely heavily on individuals with European ancestry.

“It is important to include individuals from different ancestral backgrounds in genetic studies because it provides a more complete understanding of the genetic basis of alcohol behaviors and other conditions, all of which contributes to a more inclusive and accurate understanding of human health,” she said. “The study of only one group of genetically similar individuals (for example, individuals of shared European ancestry) could worsen health disparities by aiding discoveries that will disproportionately benefit only that population.”

She said their study opens numerous doors for future research, chasing down possible connections between the alcohol-protective alleles and conditions that have no apparent connection with alcohol consumption.

“Understanding the underlying mechanisms of these effects could have implications for treatments and preventative medicine,” Sanchez-Roige noted. 

Co-authors on the paper from the University of California San Diego School of Medicine Department of Psychiatry are Mariela V. Jennings, Natasia S. Courchesne-Krak, Renata B. Cupertino and Sevim B. Bianchi. Sandra Sanchez-Roige is also associated with the Department of Medicine, Division of Genetic Medicine, Vanderbilt University.

Other co-authors are: José Jaime Martínez-Magaña, Department of Psychiatry, Division of Human Genetics, Yale University School of Medicine; Laura Vilar-Ribó, Psychiatric Genetics Unit, Group of Psychiatry, Mental Health and Addiction, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Alexander S. Hatoum, Department of Psychology & Brain Sciences, Washington University in St. Louis; Elizabeth G. Atkinson, Department of Molecular and Human Genetics, Baylor College of Medicine; Paola Giusti-Rodriguez, Department of Psychiatry, University of Florida College of Medicine; Janitza L. Montalvo-Ortiz, Department of Psychiatry, Division of Human Genetics, Yale University School of Medicine, National Center of Posttraumatic Stress Disorder, VA CT Healthcare Center; Joel Gelernter, VA CT Healthcare Center, Department of Psychiatry, West Haven CT; and Departments of Psychiatry, Genetics & Neuroscience, Yale Univ. School of Medicine; María Soler Artigas, Psychiatric Genetics Unit, Group of Psychiatry, Mental Health and Addiction, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Mental Health, Hospital Universitari Vall d’Hebron, Barcelona; Biomedical Network Research Centre on Mental Health (CIBERSAM), Madrid; and Department of Genetics, Microbiology, and Statistics, Faculty of Biology, Universitat de Barcelona; Howard J. Edenberg, Department of Biochemistry and Molecular Biology, Indiana University School of Medicine; and the 23andMe Inc. Research Team, including Sarah L. Elson and Pierre Fontanillas.

The study was funded, in part, by Tobacco-Related Disease Research Program grants T32IR5226 and 28IR-0070, National Institute of Health (NIH) National Institute of Drug Abuse (NIDA) DP1DA054394, and NIH National Institute of Mental Health (NIMH) R25MH081482. 

“These variants…tend to prevent alcohol use disorder, because these variants are primarily associated with the quantity of alcohol someone may drink.”

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Application of transtheoretical model in management of individual with alcohol dependence: A case study

Romalin pattanaik.

Department of Clinical Psychology, Mental Health Institute, SCB MCH, Cuttack, Odisha, India

Narendra Nath Samantaray

Jashobanta mohapatra.

Studies have focused on the efficacy of transtheoretical model in the management of substance dependence, but not much have focused on the changes with respect to the patient's mood, life skills, and interpersonal relationship issues that take place during the therapy. The present study explores a case by using motivational interviewing and relapse prevention strategies to qualitatively record the applicability of the transtheoretical model in terms of readiness to change, action taken, relationship conflicts, assertiveness, and depression in an individual with alcohol dependence. The intervention was carried out over 3 months for ten sessions followed by follow-up for 8 months. The results indicated improvement in the patient in the dimensions of level of action taken for increasing abstinence period, decreasing the level of depression, enhancing readiness to change, and improving assertiveness and improvement in marital adjustment with spouse, which were observed and reported during the post follow-up sessions.

Many psychological models for the management of alcohol dependence have been studied. Among such models, transtheoretical model (TTM) is considered to be highly influential,[ 1 ] as it adopts an approach to make the clients understand the complexities of change and to prepare them to adapt to it creatively. The model focuses on incorporating counseling procedures based on motivational interviewing and relapse prevention strategies in the treatment approaches. Hence, the present study aims to examine the efficacy of TTM with the combination of motivational interviewing and relapse prevention strategies in the dimensions of readiness to change, action taken, relationship conflict, assertiveness, and depression in individuals with alcohol dependence.

CASE REPORT AND CONCEPTUALIZATION

Mr. A, a 37-year-old, married Hindu male, employed as a laboratory technician, hailing from a middle socioeconomic family of an urban area of Cuttack district, Odisha, reported with chief complaints such as regular consumption of alcohol, being in an irritable mood most of the time, and engaging in feud with his wife. From the point of study, he had been taking alcohol for the last 8 years, which has increased for the last 2 years. Initially, the amount used to be taken was 750 ml/day. Since the last 2 years, the quantity of alcohol taken has increased to 1500–2000 ml/every day. The period of abstinence during these years was limited to a few days; the maximum abstinence period was 16 days. The case reported of no other physiological or psychological withdrawal symptoms except feeling distress and disturbance of sleep. He reported an increased urge to take the substance during 2–5 pm and after 9 pm (critical time).

Mr. A reported that he was experiencing more stress because his wife was asking for a divorce which he did not want. He reported that due to his habit of alcohol, conflicts with his wife escalated. The patient reported that he as a laboratory technician has been able to perform his job properly. Impairment was reported more in his familial relations. The patient had gradually limited himself to few of his friends; he had started avoiding his relatives as they used to ask him to quit alcohol.

He had attempted few times to quit alcohol but was unable to maintain the sobriety for long. He had willingly come for therapy with his wife to save their relationship. A detailed therapy structure was planned out based on the client's problems, which is discussed in the later part of the article.

His maintaining factors of addiction can be summed up as follows: proximity of bar to his clinic, difficulty in coping with familial tensions, withdrawal symptoms (insomnia and psychological distress), lack of assertiveness, and impulsive behavior.

Protective factors were his attachment to his son, love for his wife, and willingness to save his marital relationship.

The present study adopted a case study, a single-subject approach. The participant was selected purposively from MHI, SCB Medical College, Cuttack, Odisha, India, for the study upon his consent. A detailed clinical history was taken. After baseline assessment, using outcome measures, intervention for 3 months, consisting of ten sessions, was administered, followed by re-assessment in post follow-up sessions and all subsequent follow-up periods for 8 months.

Outcome measures

During the initial interview, information related to precipitating, maintaining, and protective factors was taken. All outcome measures were assessed at baseline, post assessment, and at follow-up stages.

• Beck Depression Inventory-II: It is a 21-item self-report scale used to assess the severity of depression[ 2 ]
• Stages of Change Readiness and Treatment Eagerness Scale: It is an instrument designed to assess readiness for change in alcohol abusers[ 3 ]
• The Relationship Assessment Scale: It is a 7-item scale that measures overall general satisfaction in couples[ 4 ]
• The Rathus Assertiveness Schedule: It is a 30-item schedule that measures assertiveness.[ 5 ]

As shown in Table 1 , the result had been analyzed in terms of preassessment, postassessment, and follow-up measures; additionally, a narrative report on session basis had also been provided.

Scores on outcome measures at different preassessment, postassessment, and follow-up stages

PS – Patient score; WS – Wife score; R – Recognition; AM – Ambivalence; TS – Taking Steps; BDI – Beck Depression Inventory; SOCRATES – Stages of Change Readiness and Treatment Eagerness Scale; FU – Follow-up

Course of treatment and assessment of progress

The therapeutic package was conducted in ten structured sessions incorporating various strategies and techniques adopted from the TTM, motivational interviewing, and the relapse prevention paradigm.

• Session 1: The session began with training in coping skills in high-risk situations, interpersonal conflict, and crisis intervention involving his wife as a co-therapist. Homework session involved risk–benefit analysis
• Session 2: Homework assignments were analyzed, and discussion on decisional balance and motivational interviewing[ 6 ] was done. Techniques employed were asking open-ended questions, affirmation, reflective listening, and summarizing
• Session 3: In this session, we discussed on how to handle possible triggers and introduced the FRAME technique (Feedback, Responsibility, Advice, Menu of alternative change options, Empathy, and Self-efficacy)
• Session 4: In this session, strategies for “Coping with Urges” through the use of urge surfing technique were done
• Session 5: In this session, further discussion and elaboration on assertiveness skill was done
• Sessions 6, 7, and 8: These three sessions were meant for couple therapy exclusively. We focused on behavioral contacting, communication, and receptive skills between them
• Sessions 9 and 10: These sessions focused on relapse prevention strategies.[ 7 ] The patient was encouraged to develop activities such as meditation, exercise, or yoga.

Post assessment

The scores on “taking steps” reflect that the patient is already doing things to bring a positive change in his drinking behavior, and he may have experienced some success in this regard. The scores on “ambivalence” indicate that he has become more accepting and open about his drinking problem. Change is underway; he is motivated such that he may want help to persist or to prevent backsliding. Subjectively, he reported improvement in his skills in relation to coping with urges and assertiveness along with marital adjustment and satisfaction level.

Both the patient and his spouse were called for follow-ups twice in the 1 st month and once in a month for the next 6 months. During the 1 st month, the patient reported that he had consumed alcohol once in a party with his friends during the past month. His relationship with his uncle has become affable, but still he is not willing to meet any of his friends and relatives.

In the 2 nd -month follow-up, the couple reported development in marital adjustment and also he has started meeting his friends and relatives and is trying to express assertiveness when required.

In the last 6-month follow-up sessions, the patient's spouse reported that he has taken alcohol twice but spent more qualitative time with the family members and started his own business. The patient reported that he has been dealing earlier reported triggers of drinking very comfortably and is able to deny his friends when they offer him a peg, and his drinks limited to social parties averaging 30–60 ml/month.

The findings of the present study were supported by a similar study which was conducted[ 8 ] to measure the effectiveness of a short-term alcohol-focused intervention for women with marital distress and to see the changes in their relationship functioning. At 1-month follow-up, the results indicated that the intervention was associated with quantitative reduction in alcohol use, marital distress, relational issues, and depression, and these changes were maintained at 12-month follow-up. However, in our study, in addition to similar variables, i.e., alcohol use, marital satisfaction, and depression, we have also included assertiveness. Our results showed improvement in all the above-mentioned dimensions of the study, which was maintained till the last follow-up. Another randomized controlled trial study was done[ 9 ] which had used motivational enhancement therapy (MET) for mild-to-moderate alcohol dependence. The results indicated that for patients with mild-to-moderate alcohol dependence, MET is more effective in reducing unequivocal heavy drinking than either a feedback/education session alone. Similar findings in other studies supported the effectiveness of motivational interventions and TTM with multiple components for reducing drinking problems in individuals.[ 10 ]

Limitations of the study

Findings gathered from a case study are difficult to generalize. In the present study, certain factors such as the patient's insight, support from his wife, and support from his family members might have played a role in the improvement of the patient, which were not measured in the study.

The present study supports the application of TTM in the management of individuals with alcohol dependence on increasing the level of action taken for prolonged abstinence period, decreasing the level of associated depression, enhancing readiness to change, improving assertiveness related to dependence, and bringing improvement in marital adjustment with spouse.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.