DRAM Vol. 5(11) – Which comes first – the drink or the distress?

December 30, 2009

Previous studies have demonstrated a
higher prevalence of psychiatric disorders among individuals with alcohol use
disorder (AUD) than among the general population (Grant et al., 2004; Kessler et al., 1996). However, there is limited literature that examines both the
co-occurence and the temporal ordering (i.e., which disorder occurs first) of
AUD and other psychiatric disorders. This week’s DRAM reviews a study that aims
to fill this gap in the literature (Flensborg-Madsen et al., 2009).

Method

    • Investigators
      analyzed 25 years of follow up data for 18,146 individuals from
      Copenhagen, Denmark.
    • The
      data reflected all admissions to Danish hospitals since 1976 and the data
      from the Danish Psychiatric Central Register since 1969.
    • The
      investigators classified individuals by diagnostic record for mood
      disorders, psychotic disorders, anxiety disorders, personality disorders,
      drug use disorder, and alcohol use disorder (AUD). 
    • The
      researchers analyzed the data by means of Cox regression analysis, which
      is a type of survival
      analysis      .

Results

o         
Among individuals with AUD (N = 1,756), 50% had
a lifetime comorbid psychiatric disorder.

      • Personality
        disorders were the most common comorbid disorders (24%, N = 421),
        followed by mood disorders (16.8%, N = 295) and drug abuse (16.6%, N =
        291).
    • As
      Table 1 shows, the risk of developing a psychiatric disorder among AUD
      individuals (N = 1,200) was larger than the risk of developing an AUD among
      individuals who were already registered with another psychiatric disorder
      (N = 2812).

 

Table 1. Risk of AUD for individuals with
psychiatric disorders and risk of psychiatric disorders for individuals with
AUD adjusted for sex, smoking, cohabitation status and educational level.

            Initial     

           
disorder

 

  Future

  disorder

 

AUD

Mood disorder

 

Psychotic disorder

 

Anxiety disorder

Personality disorder

 

Drug abuse

AUD

 

4.5

3.2

3.4

4.3

5.1

Mood
disorder

4.8

 

Psychotic
disorder

4.5

 

Anxiety
disorder

6.4

 

Personality
disorder

8.1

 

Drug
abuse

18.3

 

Note: Data are presented in the form of odd-ratios.

Limitations

  • The
    time of disorder onset is based on a diagnostic record and not a report of
    onset; consequently, the timing of AUD and other psychiatric disorders
    might reflect the order of treatment seeking or clinician recognition of a
    problem, not the actual onset.
  • The
    sample contains only individuals who were diagnosed with a psychiatric
    disorder.
  • Even
    if alcohol orders tend to precede other psychiatric disorders, this study
    does not provide evidence for a causal link between the two.

 

Conclusion

Comorbidity of AUD with other psychiatric disorders is the rule rather
than the exception. These findings show that, for individuals who have been
diagnosed with AUD, the risk of subsequently receiving a diagnosis for other
psychiatric disorders is higher than the risk for individuals who have been
diagnosed with other psychiatric disorders to receive a subsequent diagnosis of
AUD. However, previous findings have shown that among people with both a psychiatric
and an addictive disorder, psychiatric disorders typically occur first (Kessler
et al., 2008; Kessler et al., 1996). This
contradiction might be explained by the fact that the researchers in the
current study used the onset of treatment as the definition of disorder onset.
It might be that individuals with both AUD and psychiatric disorder register to
the hospital to receive treatment for the AUD first. It also might be
that individuals with comorbid AUD register at the hospital more frequently
than individuals without comorbid AUD. Overall, these findings imply the need to
develop improved and integrated treatment for individuals meeting criteria of
AUD and other psychiatric disorders.

 

-Julia Braverman

 

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feedback on this article.

References

Flensborg-Madsen, T., Mortensen, E. L., Knop, J.,
Becker, U., Sher, L., & Grønbæk, M. (2009). Comorbidity and
temporal ordering of alcohol use disorders and other psychiatric disorders:
Results from a Danish register-based study. Comprehensive Psychiatry, 50(4), 307-314.

Grant, B. F., Stinson, F. S., Dawson, D. A., Chou,
S. P., Dufour, M. C., Compton, W., et al. (2004). Prevalence and
co-occurrence of substance use disorders and independent mood and anxiety
disorders. Archives of General
Psychiatry, 61, 807-816.

Kessler, R. C.,
Hwang, I., LaBrie, R. A., Petukhova, M., Sampson, N. A., Winters, K. C., et al.
(2008). DSM-IV pathological gambling in the National Comorbidity Survey
Replication. Psychological Medicine 38(9),
1351-1360.

Kessler, R. C.,
Nelson, C. B., McGonagle, K. A., Edlund, M. J., Frank, R. G., & Leaf, P. J.
(1996). The epidemiology of co-occurring addictive and mental disorders:
Implications for prevention and service utilization. American Journal of Orthopsychiatry, 66(1), 17-31.