ABSTRACT
In recent years, consumption of alcoholic beverages has become a common practice among young adults attending higher education institutions in Mexico. Over the past two decades, prevalence of alcohol consumption in this population has doubled. In campuses located in Mexico City, 70-90% of undergraduate students have consumed alcoholic beverages during the past year and approximately 25% have engaged in binge drinking. Past year prevalence of Alcohol Dependence (AD) has been estimated in 4.6% and 18.4%. Higher education institutions around the world have implemented programs aimed at reducing students' drinking that have included educational interventions and/or psychosocial treatments delivered individually or in group format. In this regard, the available evidence suggests that programs that have included elements of the Motivational Enhancement Therapy (MET) or components of the Cognitive Behavioral Therapy (CBT) have shown the greatest efficacy in reducing drinking problems in this population. Despite this, there are no studies examining the efficacy of these interventions in Mexico's college student population. In the report presented here, we aim at examining the efficacy of Individual or Group MET and CBT in reducing drinking among undergraduate students diagnosed with AD. We hypothesized that in comparison to CBT, MET would show evidence of a greater reduction in alcohol consumption. To evaluate this hypothesis we examined the treatment effects on the number of consumed drinks, on the number of drinking days, and on the number of drinks per drinking day during the preceding 30 days. Methods We prospectively evaluated during an 8-week treatment phase and during a 12-month follow-up period, 158 undergraduate students who received a diagnosis of AD (ICD-10) at the students' Mental Health and Counseling Center of the National Autonomous University of Mexico (UNAM) in Mexico City. Instruments. In order to screen and to establish the diagnosis of AD we respectively used the Alcohol Use Disorders Identification Test (AUDIT) Mexican version and the Composite International Diagnostic Interview (CIDI). We also used The Alcohol Time line Followback (TLFB) method to retrospectively record the amount and frequency of alcohol consumption. Procedures. Students seeking services at the UNAM Mental Health and Counseling Center, and who had a diagnosis of AD, were invited to participate in the study. After informed consent was obtained, they were randomly assigned to one of four manualized treatment interventions: Individual or Group MET, or Individual or Group CBT. These were delivered in eight weekly sessions lasting one hour. The alcohol TLFB was administered at the beginning and at the end of the 8-week treatment phase, and subsequently monthly for the following 12 months. Statistical analysis. An analysis of variance (ANOVA) for repeated measures was used to examine the treatment effect on drinking during the treatment phase and separately during the 12-month follow-up period. A one-way ANOVA was used to examine differences between treatment groups at specific assessment points. Results Demographic characteristics. In the entire sample the majority of students were men (73.2%), while the mean age was 18.8 [± 2.9] years. There were no differences between intervention groups in their demographic characteristics. Baseline characteristics of alcohol consumption. In the entire sample and separately in each of the intervention groups there was a predominant pattern of weekly heavy drinking. There were no baseline differences between treatment groups in the monthly amount or frequency of drinking, or in the number of drinks consumed during drinking days (all comparisons P>0.50). The average number of Alcohol Dependence symptoms was 6.0 [± 2.6]. There were no differences among groups in the number of these symptoms (P=0.10). Patient Retention during the Treatment Phase and the Follow-up Period. At the end of the 8-week treatment phase, 92% of the students remained in treatment. During this phase, the Individual CBT group had the greatest number of dropouts with 18% of them leaving prematurely (Pearson X² = 15.7, df=3, P = 0.001). During the follow-up period, specifically at the 3, 6 and 12-month follow-up, the retention rates in the study were respectively 91%, 89% and 86%. There were no differences among groups in this variable at any of these follow up points. Alcohol consumption during the treatment phase. In the ANOVA for repeated measures we found that during the treatment phase there was a main effect of time over the three indicators of alcohol consumption (range of F: 7.59-11.81, df=1.142, range of P:0.001-0.007). This reflected the fact that at the end of the four interventions there was a reduction in the amount and frequency of monthly drinking and a reduction in the number of drinks during drinking days. There were no main effects of treatment (range of P:0.07- 0.56) or interactive time X treatment effects (range of P:0.55 to 0.79) on any of the drinking variables. However, at the level of a non-significant trend (F = 2.37, df=3.143, P = 0.07), there was a treatment effect reflecting that in comparison to Individual CBT, there was a trend toward a greater reduction in the frequency of monthly drinking in Group MET (one-way ANOVA: F=2.60, df=3.146, P=0.05, Tukey HSD P=0.07). Alcohol consumption during the follow-up period. In the ANOVA for repeated measures, there was a main effect of time on the amount and frequency of monthly alcohol consumption (range of F: 8.54-9.53, df=3.393, P range: 0.001-0.004), reflecting that during this period there was a reduction in these two drinking variables in the entire sample. This effect was observed mainly during the first six months of follow-up. During the following six months, there was a gradual increase in the amount and frequency of drinking (range of F for the quadratic component of Time: 5.36-10.36, df=1.131, range of P: 0.02-0.002) that approached the levels seen at the end of treatment. There were no main effects of time on the number of drinks consumed during drinking days (P=0.27). There was a treatment X time interaction (F=2.65, df=3.131, P=0.05) on monthly frequency of drinking, indicating that, in comparison to Individual CBT, there was a greater reduction in this drinking variable in Group MET. This effect was specifically observed during the first three months of follow-up (one-way ANOVA: F=3.63, df=3.142, P=0.02, Tukey HSD P=0.007). Subsequently, there were no differences among the intervention groups in this variable for the remaining nine months of follow-up. Finally, there were no main effects attributable to treatment or interactive effects of time X treatment on the number of monthly drinks (P range: 0.49 to 0.65) or on the number of drinks consumed per drinking day (P range: 0.55 to 0.79). Discussion In this sample of alcohol dependent college students, we found that at the end of the 8-week treatment phase there was a comparable reduction in the amount and frequency of alcohol consumption and in the number of drinks consumed during drinking days across the four intervention groups. However, we observed that at the level of a non significant trend (P=0.07), Group MET appeared to be more effective than Individual CBT in reducing the frequency of alcohol drinking.
Introducción Se ha descrito que entre los estudiantes de educación superior de nuestro país la prevalencia del consumo de alcohol se ha duplicado durante las últimas dos décadas. Se han estimado prevalencias durante los últimos 12 meses del diagnóstico de Dependencia al Alcohol (DA) de 4.6%. Aunque se desconoce la magnitud de las consecuencias de estos problemas entre los estudiantes universitarios mexicanos, en Estados Unidos han sido identificados como un problema de salud pública mayor y como el principal problema de salud en las universidades. Para reducir estos problemas, se ha evidenciado que las intervenciones como la Terapia de Incremento de la Motivación (TM) o la Terapia Cognitivo Conductual (TCC) podrían ser igualmente efectivas a largo plazo. Se ha observado una ligera ventaja del formato individual sobre el grupal. Pero al analizar el costo-beneficio, el formato grupal suele ser el más utilizado en las universidades. A pesar de la importancia de los problemas por consumo de alcohol en las universidades y no obstante la efectividad demostrada de estas intervenciones, no hay, hasta lo que sabemos, investigaciones publicadas que comparen la eficacia de la TM y la TCC en el tratamiento de los universitarios con problemas por consumo de alcohol en México o en otros países de habla hispana. Objetivo Examinar los efectos de las intervenciones TM y TCC tanto en su modalidad individual como grupal, en el tratamiento de estudiantes universitarios con diagnóstico de dependencia al alcohol. Material y métodos Se evaluó prospectiva y comparativamente a 158 estudiantes universitarios con diagnóstico de Dependencia al Alcohol. Instrumentos: 1. Alcohol Use Disorders Identification Test (AUDIT); 2. Composite International Diagnostic Interview (CIDI); 3. Línea Base Retrospectiva (LIBARE); 4. Cuestionario de Datos Demográficos. Procedimientos. A los estudiantes con problemas con su manera de beber, se les aplicó el AUDIT; a los que tuvieran respuestas positivas para Dependencia al Alcohol, se les aplicó la sección de <
ABSTRACT
Alcohol is commonly used among adolescents in Mexico. In a representative survey of Mexico's general population, 30% of the teenagers reported current drinking, whereas 8% incurred in binge drinking (5 or more drinks per occasion) at least once during the last year. In addition, 3% reported three or more alcohol dependence symptoms over the last 12 months. In this Mexican age group, alcohol consumption importantly contributes to the most frequent causes of morbidity and mortality (e.g. accidents, violence, homicides, suicide and risky behaviors). Data from a representative survey of adolescents attending middle and high school in Mexico City suggests that adolescents attending Mexico's schools run a high risk for alcohol problems. In this study, prevalence of lifetime and current drinking, and of current binge drinking (5 or more drinks per occasion) were, respectively, 65.8%, 35.2%, and 23.8%. These rates are substantially higher than those described in teenagers from Mexico's general population. Furthermore, although among Mexico's general population the prevalence of drinking has traditionally been higher among male than female adolescents, no gender differences in prevalence of alcohol consumption have been reported among Mexican middle and high school students. This suggests that female adolescents in Mexico's schools have become equally exposed to drinking as their male counterparts. Despite these trends, there is a paucity of studies examining drinking patterns and their respective correlates among Mexican adolescents attending post-elementary education. To our knowledge, in this population, there are no published prevalence estimates of Hazardous and Harmful Drinking (HHD). HHD is defined as a pattern of alcohol consumption conferring to the individual a greater risk for health problems, or frankly conducive to medical or psychological complications (e.g. accidents, victimization, violence, alcohol dependence, liver cirrhosis and/or other medical complications). The Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization, is currently the only instrument specifically designed to identify HHD. Although the AUDIT was initially validated only among adult patients in primary care settings, this instrument has consistently shown to be valid and reliable in detecting alcohol problems in different populations, such as the adolescent population in many countries around the world. Given the public health implications of estimating the frequency of HHD among adolescents attending high school in Mexico, and given the importance of elucidating the variables influencing this problem, we decided to conduct the analysis presented here. To our knowledge, this is the first report published in the international literature on the prevalence of HHD among adolescents attending high school in a Latin American country. Objective In the study described here, derived from a Universidad Nacional Autónoma de México (UNAM) project entitled <
De acuerdo a la Encuesta Nacional de Adicciones (ENA) (Medina-Mora et al., 2003), de 1990 al 2002, la prevalencia en el consumo de alcohol durante los últimos 12 meses entre los jóvenes mexicanos de 12 a 17 años de edad, se elevó del 27.6% al 30%. De manera más reciente, la Encuesta de Estudiantes de Nivel Medio y Medio Superior de la Ciudad de México (EENMMS) (Villatoro et al., 2003), describió que el consumo alguna vez en la vida y el consumo durante el último mes de bebidas etílicas afectó respectivamente al 65.8% y al 35.2% de los estudiantes. Llama la atención que la frecuencia del consumo alguna vez en la vida reportada por la EENMMS es considerablemente mayor que la descrita en los adolescentes de la población general urbana (39.8%) por la ENA. Además, las diferencias de género reportadas por la ENA, en las que los hombres tradicionalmente beben con más frecuencia que las mujeres, no fueron encontradas por la EENMMS en la población estudiantil del nivel medio y medio superior. Hasta lo que nosotros sabemos, se desconoce cuál es la prevalencia en esta población de patrones de consumo problemático de alcohol como serían el consumo riesgoso y dañino (CRDA) o el consumo dependiente. Por lo que se desconoce si existen diferencias entre la población estudiantil y los adolescentes de la población general, en la prevalencia de estos problemas. El CRDA se define como un patrón de consumo de bebidas embriagantes, que se sitúa en un continuum de severidad, que coloca al sujeto en riesgo de desarrollar problemas de salud y/o que puede desembocar en francas complicaciones físicas y/o psicológicas (accidentes, victimización, violencia, dependencia al alcohol, etc.). Objetivo En el estudio que se presenta aquí, nos propusimos: 1) estimar la prevalencia durante el último año del CRDA en los estudiantes de primer ingreso al nivel bachillerato de la UNAM, y 2) evaluar la influencia de las variables sociodemográficas y familiares en el riesgo para el CRDA. Material y métodos El diseño del estudio fue el de una encuesta transversal en los estudiantes del primer año del bachillerato en el sistema escolarizado de la UNAM. Se estudiaron a 28 784 estudiantes (87.4 % de la población total). Se utilizó el Alcohol Use Disorders Identification Test (AUDIT) -versión en español para detectar el CRDA en la población adolescente. En este análisis empleamos tanto los puntos de corte recomendados para evaluar el CRDA en adultos (AUDIT≥8) como el puntaje recomendado para la población adolescente (AUDIT≥3). Se utilizaron porcentajes, promedios y desviaciones estándar para el análisis de las variables demográficas, y pruebas de contraste de medias (análisis de varianza) y de proporciones ( χ²) de acuerdo a la variable. Se utilizó la regresión logística multinomial para examinar la asociación de las variables demográficas y familiares con el CRDA. Se calcularon los odds ratios (OR) con intervalo de confianza al 95% para resumir el nivel de riesgo de ser afectado por el CRDA. Resultados Cuando se usó la definición del CRDA para la población adulta, se encontró que 4.0% de los estudiantes lo presentaron, frente a 1 7.2% cuando se utilizó el puntaje del AUDIT recomendado para los adolescentes. El riesgo de experimentar el CRDA fue casi dos veces mayor en los hombres que en las mujeres.
ABSTRACT
Background In Mexico, alcohol is the most widely used substance among young adults. Alcohol consumption in this age group contributes importantly to the most frequent causes of mortality and morbidity (e.g., accidents, violence, homicides, suicide and risky behaviors). Around the world, college or university attendance has emerged in the literature as a risk factor for drinking problems among young adults. In Mexico, data from the most recent National Survey on Addictions showed that lifetime and current drinking is experienced by more than half of the Mexicans attending college education. Despite this, in our country there is a paucity of epidemiological studies examining drinking behavior and correlates among those attending college. Findings in non-representative samples of students attending public and private universities in Mexico City suggest that, during the last two decades, there has been an increase in the frequency of lifetime and current drinking in this population. Additionally, these studies have shown that, in comparison to young adults of the same age in the general population, university students may experience a greater prevalence of lifetime and current alcohol drinking. Regarding the frequency of unhealthy drinking among Mexican college students, to our knowledge there are no prevalence estimates of hazardous or harmful drinking published. However, observations in non-random samples of university students in Mexico City suggested that at least one in three men and one in five women incurred in unhealthy drinking (e.g., ≥ 5 drinks per occasion or drinking to intoxication) at least once during the last month. Hazardous and harmful drinking is respectively defined by a pattern of alcohol consumption conferring a greater risk for health problems or that is frankly conducive to medical or psychological complications (e.g., accidents, victimization, violence, alcohol dependence, liver cirrhosis and/or other medical complications). The Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization, is currently the only instrument specifically designed to identify hazardous and harmful drinking. Although the AUDIT was initially validated among older adult patients in primary care settings, this instrument has consistently shown to be valid and reliable in detecting alcohol problems in different populations such as the college students in many countries around the world. Given the public health implications of estimating the frequency of hazardous and harmful drinking among college students in Mexico, and given the importance of elucidating the variables influencing this problem, we decided to conduct the present study. To our knowledge, this is the first report published in the international literature on the prevalence of hazardous and harmful drinking among college students in a Latin American country. Objective In the analysis described here, derived from the project entitled Early Identification and Treatment of Problem Drinkers at the National Autonomous University of Mexico (UNAM), our aim was to examine the frequency and risk factors for hazardous and harmful drinking among Mexican university students. More specifically, our objectives were: 1. To determine the past-year prevalence of hazardous and harmful drinking among UNAM college freshmen; and 2. To examine in this population the effects of demographic and family variables on the likelihood of hazardous and harmful drinking. Subjects and methods This study was a cross-sectional survey that was conducted at the beginning of the school year during the registration period between September 1st and September 30th, 2005. In 2005, a total of 34 000 students were accepted to initiate college at the nine UNAM college campuses located in the Mexico City metropolitan area. Of these, 24 921 (73.3%) students (age=18.7±4.3 years; 55.7% women) consented in answering the survey and provided complete data. Consequently, 9 079 students (26.7%) were excluded from the analysis due to lack of consent, incomplete data or due to their absence at the time of registration. We used the Alcohol Use Disorders Identification Test (AUDIT) to examine past-year prevalence of hazardous and harmful drinking. This self-report instrument includes 10 items that examine frequency and intensity of drinking (items 1-3), presence of alcohol dependence symptoms (items 4-6) and negative consequences of drinking (items 7-10), yielding a maximum possible score of 40 points. Among adult patients in primary care settings, it has been accepted that an AUDIT score of 0-7 points reflects safe levels of alcohol consumption, whereas a score of 8 points or greater indicates the presence of hazardous and harmful drinking. It has been described, however, that among college students, an AUDIT score of 6 points or greater reliably identifies those students experiencing this problem. In the analysis presented here, we separately examined and reported the prevalence estimates and correlates of hazardous and harmful drinking using both AUDIT cut-off scores (≥ 6 and ≥ 8). The AUDIT was administered at the same time as a wellness screening survey that the UNAM Medical Services routinely administer to all registering freshmen at the beginning of the school year. Questions in the wellness survey pertained students' medical and dental health, family medical history, immunizations, use of tobacco and other drugs. In addition, demographic and socioeconomic information was obtained from a questionnaire also routinely administered by the UNAM registrar's office. This questionnaire included 37 items inquiring about gender, age, employment and marital status, monthly family income, parental education, place and type of residency, persons with whom the student resided, and questions on previous academic performance.
Antecedentes En México, el alcohol es la sustancia potencialmente adictiva que se utiliza con mayor frecuencia por los adultos jóvenes. Información proveniente de la Encuesta Nacional de Adicciones más reciente muestra que más de 50% de los jóvenes entre los 18-29 años ha consumido bebidas alcohólicas al menos una vez durante el último mes. En la Ciudad de México se ha encontrado que más de la mitad de las mujeres y cerca de dos terceras partes de los hombres entre 18-29 años de edad consume regularmente bebidas alcohólicas. Durante los últimos años, el consumo de bebidas alcohólicas se ha venido incrementando importantemente entre los jóvenes mexicanos de ambos sexos en edad de recibir una educación superior. A nivel internacional, la bibliografía sugiere que la población estudiantil de los centros de educación superior es un grupo de mayor riesgo para el desarrollo de problemas por consumo de alcohol. En México, aunque se desconoce si los estudiantes de educación superior son un grupo de mayor riesgo para estos abusos, algunas encuestas y reportes sugieren que los problemas por consumo de alcohol tienen una importancia creciente. En cuanto al consumo de alcohol que excede los niveles seguros para la salud (≥2 bebidas estándar al día en las mujeres o ≥3 bebidas estándar al día en los hombres), el Observatorio Mexicano del Alcohol y Drogas describió que en el año 2002 el consumo de cinco o más copas por ocasión de consumo afecta a tres de cinco hombres y a una de cinco mujeres. Aunque problemas metodológicos y sesgos de selección potenciales en estas encuestas dificultan su interpretación, sus resultados sugieren que el consumo de alcohol, particularmente el consumo riesgoso y potencialmente dañino, es común entre los estudiantes universitarios de la Ciudad de México. El consumo riesgoso y dañino de alcohol (CRDA) se sitúa en un continuum de severidad y se define como un patrón de consumo de bebidas embriagantes que colocan al sujeto en riesgo de desarrollar problemas de salud y/o que desemboca en francas complicaciones físicas y/o psicológicas (accidentes, victimización, violencia, dependencia al alcohol, cirrosis hepática, etc.). De acuerdo a los reportes de la bibliografía internacional, este es el primer estudio publicado sobre la prevalencia de consumo peligroso y dañino de alcohol en estudiantes universitarios en América Latina. Objetivo En el trabajo que se presenta aquí, que forma parte del proyecto para la Identificación Temprana y Tratamiento Oportuno de bebedores con Consumo Excesivo de Alcohol en Estudiantes Universitarios de la UNAM, nos propusimos evaluar la prevalencia del CRDA durante el último año y examinar los factores de riesgo y protección respectivos en estudiantes de primer ingreso a la licenciatura de la Universidad Nacional Autónoma de México. De manera especifica, nos propusimos: 1) estimar la prevalencia del CRDA durante el último año en los estudiantes de primer ingreso a la licenciatura de la UNAM, y 2) evaluar en esta población la influencia de las variables sociodemográficas y familiares en el riesgo para el CRDA. Material y métodos Se trató de un estudio transversal en el que se estudiaron 24921 estudiantes del primer año de la licenciatura de la UNAM (edad=18.7±4.3 años; 55% mujeres). Para detectar aquellos estudiantes que en el último año incurrieron en el CRDA, se utilizó el instrumento de tamizaje Alcohol Use Disorder Identification Test (AUDIT). Se utilizó la regresión logística multinomial para examinar los efectos de las variables demográficas y sociofamiliares, así como para calcular Odds Ratios (OR) y sus respectivos intervalos de confianza al 95%. Este instrumento consiste de 10 preguntas que exploran la frecuencia e intensidad del consumo de bebidas alcohólicas. Con el objetivo de poder comparar nuestros hallazgos con los de otros investigadores, se examinaron y se reportan separadamente las prevalencias del CRDA con base en puntos de corte de 8 y de 6 en el AUDIT. Para el reporte de datos demográficos y puntajes del AUDIT, se utilizaron porcentajes, promedios y desviaciones estándar. Se emplearon las pruebas de contraste de medias (análisis de varianza) y de proporciones (χ2) dependiendo de la naturaleza de cada variable. Se calcularon las prevalencias del CRDA con sus respectivos intervalos de confianza al 95%. Resultados Usando un puntaje de corte en el AUDIT de ocho y de seis puntos, la prevalencia del CRDA durante el último año fue respectivamente de 11.1% y de 18.4%. Esta fue mayor en los hombres (AUDIT≥8: 17.3%; AUDIT≥6: 27.4%) que en las mujeres (AUDIT≥8: 6.2%; AUDIT≥6: 11.3%). Además del sexo masculino, aquellos estudiantes que trabajaban y que reportaron un mayor ingreso familiar mensual, tuvieron un mayor riesgo de experimentar el CRDA. En las mujeres, pero no en los hombres, un mayor nivel educativo tanto en el padre como en la madre también se relacionó con un incremento en el CRDA. Contrariamente, una mayor edad y el ser casado se asoció con una reducción en el riesgo del CRDA.
ABSTRACT
El presente artículo presenta un panorama general sobre las atribuciones que tiene la Comisión Nacional de Arbitraje Médico (CONAMED) para vigilar el cumplimiento de la prestación de servicios de salud, así como de la calidad de atención médica prestada por las diversas instituciones de salud. Dicha institución reconoce la existencia de limitaciones de carácter económico y otras, derivadas de problemas de organización, administración e incluso de actitudes del personal de salud. Se presentan las 10 especialidades médicas con mayor frecuencia de quejas