A Prospective Comparison of Bipolar I and II Subjects With and Without Comorbid Alcohol Dependence From the COGA Dataset.

Objective: Comorbidity of alcohol use disorders in bipolar subjects is high as indicated by epidemiological and clinical studies. Though a more severe course of bipolar disorder in subjects with comorbid alcohol dependence has been reported, fewer studies considered the longitudinal course of alcohol dependence in bipolar subjects and the prospective course of comorbid bipolar II subjects. Beside baseline analysis, longitudinal data of the COGA (Collaborative Study on Genetics in Alcoholism) were used to evaluate the course of bipolar I and II disordered subjects with and without comorbid alcohol dependence over more than 5 years of follow-up. Methods: Characteristics of bipolar disorder, alcohol dependence and comorbid psychiatric disorders were assessed using semi-structured interviews (SSAGA) at baseline and at a 5-year follow-up. Two hundred twenty-eight bipolar I and II patients were subdivided into groups with and without comorbid alcohol dependence. Results: Of the 152 bipolar I and 76 bipolar II patients, 172 (75, 4%) had a comorbid diagnosis of alcohol dependence. Bipolar I patients with alcohol dependence, in particular women, had a more severe course of bipolar disorder, worse social functioning and more suicidal behavior than all other groups of subjects during the 5-year follow-up. In contrast, alcohol dependence improved significantly in both comorbid bipolar I and II individuals during this time. Conclusions: A 5-year prospective evaluation of bipolar patients with and without alcohol dependence confirmed previous investigations suggesting a more severe course of bipolar disorder in comorbid bipolar I individuals, whereas bipolar II individuals were less severely impaired by comorbid alcohol use disorder. While severity of alcohol dependence improved during this time in comorbid alcohol-dependent bipolar I patients, the unfavorable outcome for these individuals might be due to the higher comorbidity with personality and other substance use disorders which, together with alcohol dependence, eventually lead to poorer symptomatic and functional clinical outcomes.

A comparison of alcohol-induced and independent depression in alcoholics with histories of suicide attempts.

OBJECTIVE: Alcohol-dependent men and women are at high risk for two types of major depressive episodes and for suicide attempts. The aim of this study is to compare the characteristics of two groups: (1) alcohol-dependent subjects with histories of suicide attempts and independent mood disorders and (2) a similar population of alcoholics with histories of self harm but who have only experienced alcohol-induced depressions. METHOD: As part of the Collaborative Study on the Genetics of Alcoholism (COGA), semistructured detailed interviews were administered to 371 alcohol-dependent individuals (62% women) with histories of suicide attempts and major mood disorders. Of the total, 145 (39.1%) had ever had an independent depressive episode and 226 (60.9%) had experienced only alcohol-induced depressions. Information was obtained about socioeconomic characteristics, suicidal behavior, independent and induced psychiatric conditions, and aspects of alcohol dependence. RESULTS: Univariate and multivariate comparisons revealed that alcohol-dependent individuals with a history of suicide attempts and independent depression had a higher number of suicide attempts, were less likely to have been drinking during their most severe attempt, and were more likely to have an independent panic disorder. Univariate analyses indicated that these subjects reported a less severe history of alcohol dependence. CONCLUSIONS: The results indicate that a distinction between independent and alcohol-induced mood disorders in alcoholics with a history of suicide attempts may be useful.

Comparison of 3190 alcohol-dependent individuals with and without suicide attempts.

INTRODUCTION: Suicidal behaviors are often seen in alcohol-dependent individuals. The aim of this study is to identify and confirm risk factors for suicide attempts in a large, family-based sample of alcoholics. METHODS: Semistructured, detailed interviews were administered to 3190 alcohol-dependent individuals as part of the Collaborative Study on the Genetics of Alcoholism (COGA). Information about suicidal behavior, socioeconomic characteristics, psychiatric comorbidity, substance use disorders, and characteristics of alcohol dependence were obtained from alcohol-dependent probands, controls, and their relatives. RESULTS: As determined by both univariate comparison and multivariate logistic regression analysis, alcohol-dependent individuals with a history of suicide attempts were found to have a significantly more severe course of alcohol dependence and a higher prevalence of both independent and substance-induced psychiatric disorders and other substance dependence. First-degree relatives of subjects with suicide attempts showed a significantly higher rate of suicide attempts, even after controlling for additional relevant diagnoses. CONCLUSION: These results support the hypothesis that alcohol-dependent individuals with a history of suicide attempts are more severely impaired. Screening and subsequent treatment of alcohol use disorder, psychiatric comorbidity, and substance use disorders among alcoholics may be crucial in preventing suicide attempts and completions.

Gender and reported health problems in treated alcohol dependent Alaska natives.

OBJECTIVE: An ongoing study of phenotypes of alcohol dependence among Alaska Natives provides the opportunity to investigate gender differences in reported health-related problems among alcohol dependent clients in three residential programs in Anchorage, Alaska. METHOD: Clinical assessment information was obtained on 469 (263 male) subjects from consecutive admissions to each of three treatment programs. The average (SD) age of the sample was 33.7 (8.4) years. Patterns of substance use, comorbid psychopathology, overall health status, alcohol and other drug withdrawal symptoms, and psychological and physical consequences of alcohol and other drug use were examined. RESULTS: Male and female subjects reported similar experiences with alcohol-related health problems, including symptoms of withdrawal and the psychological and physical consequences of chronic alcohol abuse. However, women were significantly more likely to have lifetime diagnoses of major depression and cocaine dependence, whereas men were more likely to have lifetime diagnoses of antisocial personality disorder and marijuana dependence. Women reported a lower overall health status, more medication use and pain complaints, and more negative consequences of cocaine abuse and withdrawal than did men. CONCLUSIONS: Both men and women within this sample of inpatient alcohol-dependent Alaska Natives were found to have a similar early onset and rapid progression to DSM-III-R alcohol dependence, and to report a similar prevalence of alcohol-related psychological and physical problems. Reports by women of more pain symptoms, more medication use and more negative health consequences related to their cocaine abuse, compared with men in this alcohol dependent sample, suggests additional considerations for treatment planning and intervention.

Alcohol dependence among Alaska Natives entering alcoholism treatment: a gender comparison.

OBJECTIVE: An ongoing study of phenotypes of alcohol dependence among Alaska Natives provides an opportunity to investigate the nature and patterns of alcohol problems among Alaska Native men and women admitted to treatment in three residential programs in Anchorage, Alaska. METHOD: A comprehensive, standardized clinical assessment (including the SSAGA-I diagnostic interview, family history information, personality traits and cognitive functioning) of consecutive admissions to each of the three programs is being undertaken by trained interviewers. To date, 200 (103 male) subjects have been assessed. The mean (+/- SD) age of the sample is 32+/-8.5 years old. The development of alcohol problems, the psychological and physical consequences of chronic drinking, the flushing response, withdrawal symptoms and comorbid lifetime psychiatric conditions were examined. RESULTS: The sample was characterized by an early onset of drinking and an acute exacerbation and clustering of drinking problems during late adolescence, followed by the development of severe alcohol dependence. A high lifetime prevalence of DSM-III-R major depressive disorder was found, typically complicated by chronic drinking. The rates of other substance dependencies were relatively low, except for cannabis and cocaine dependence among female subjects. CONCLUSIONS: This sample of treatment-seeking Alaska Natives was found to have an early onset and severe form of DSM-III-R alcohol dependence, with few gender differences noted. While the prevalence of alcohol abuse and alcohol dependence among Native American populations has been reported to be quite high, the onset and patterning of symptoms among this sample of treated Alaska Natives has revealed more similarities with treated alcoholics from the majority population than important differences specific to Alaska Natives.

A validity study of the SSAGA--a comparison with the SCAN.

OBJECTIVE: This study examined the concurrent diagnostic validity of the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA) across alcohol and drug dependencies, major depression, anxiety disorders and ASPD. The Schedule for Clinical Assessment in Neuropsychiatry (SCAN) was selected as the comparison instrument because it arises from a different tradition and uses a different format for its administration. The SCAN has been shown to be valid and applicable cross-culturally. METHOD: Subjects included 38 men and 42 women volunteers from another study and from an outpatient psychiatry clinic. Selected sections of both the SSAGA and the SCAN interviews were administered to all subjects, approximately 1 week apart, in a randomized order. Because the SCAN does not assess Antisocial Personality Disorder (ASPD), the ASPD section of the Structured Clinical Interview for DSM-III-R (SCID) was substituted for this comparison. RESULTS: The Kappa statistic was used to measure concordance between the two instruments. Kappa for alcohol dependence was in the acceptable range (0.63). Kappas were lower for sedative dependence (0.48) and for cannabis dependence (0.53), but higher for cocaine and stimulant dependence (0.85) and for opioid dependence (0.73). Kappa for major depression and the ASPD diagnoses were high (0.71 and 0.70), but slightly lower agreement was found for panic disorder (0.62). Kappa for social phobia was 0.47. CONCLUSION: These data, combined with results from two previous studies which examined reliability, indicate that the SSAGA is a highly reliable and valid instrument for use in studies of a variety of psychiatric disorders, including alcohol and drug dependence.

The clinical course of alcohol-related problems in alcohol dependent and nonalcohol dependent drinking women and men.

OBJECTIVE: This article examines the differences in the clinical course of alcohol dependence in men and women, interpreting results in light of the gender differences in nonalcoholics and potential findings from the general population. METHOD: As part of the Collaborative Study on the Genetics of Alcoholism (COGA) protocol, a detailed semistructured interview was administered to 1,085 alcohol dependent women and 2,120 alcohol dependent men, along with 1,936 women and 1,233 men who were drinkers but not alcoholic. Subjects were alcohol dependent probands, controls, and relatives of each. RESULTS: The men's and women's rank orders of alcohol-related life events were similar for alcohol dependent subjects, with a rho (rho) of .95, a figure that remained constant even when only primary alcoholics were considered. In general, those items for which the two genders evidenced differences in either the mean age of occurrence or the proportion of people who experienced an event were similar to gender differences in drinking among nonalcoholics or the literature on the general population. These included for women a lower maximum number of drinks per day, a 1- to 2-year later onset of several early alcohol-related problems and fewer years between the onset of problems and seeking help. Female alcoholics also showed a lower proportion with legal, job or personal problems related to alcohol. There were also high levels of similarity (p = .76, p > .001) for 28 life events related to alcohol for 1,936 women and 1,233 men who were drinkers but not alcohol dependent. CONCLUSIONS: Overall, the time course of alcohol-related problems for men and women were more similar than different. While there was evidence of a "telescoping" of the time between the onset of problems and treatment for women, the gender differences in ages of onset of events were relatively small. These data support the conclusion that, after considering gender differences in drinking in society, there is little evidence that the natural history of alcohol dependence in women is substantially different than in men.

Alcoholism and subtypes of antisocial personality disorder.

The co-occurrence of alcoholism with other psychiatric conditions among treated samples is well known. One of the most prevalent comorbid conditions among both male and female alcoholics is antisocial personality disorder (ASPD). While ASPD is known to affect the development and severity of alcoholism, comparisons of subtypes of ASPD in relation to the etiology of alcoholism have not been reported. Male and female alcoholics (n = 321) with ASPD or DSM III subtypes [Conduct Disorder; Adult Onset ASPD] were compared to non-ASPD alcoholics on several etiological features of alcoholism and its clinical presentation immediately prior to treatment. The results show that alcoholics with a subtype of ASPD, even if it occurred predominately during childhood, have a form of alcoholism similar to ASPD alcoholics. Further, the severity of alcoholism among persons with ASPD may vary according to the severity of the ASPD.

Relationship of family history, antisocial personality disorder and personality traits in young men at risk for alcoholism.

Studies examining possible risk factors for the development of alcoholism have focused recently on a variety of personality factors, including those associated with risk-taking behaviors. Alcohol-seeking behavior leading to the abuse of alcohol may be associated with a variety of risk-taking behaviors that derive from certain personality traits. Further, there is evidence that personality traits are transmitted across generations. This study examined the relationship of a family history of alcoholism, antisocial personality disorder (ASP) and alcohol use to several personality traits including the Tri-dimensional Personality Questionnaire (TPQ) in a sample (N = 91) of nonalcoholic, young male volunteers. The men with ASP scored higher than the non-ASP men on the Novelty Seeking Scale of the TPQ, but not on the Harm Avoidance or Reward Dependence subscales. In addition, ASP men scored higher than non-ASP men on a measure of impulsivity and tended to score higher on measures of sensation seeking, psychopathy and monotony avoidance. A family history of alcoholism did not differentiate the young men on any of the childhood behavior problems, personality measures or alcohol-related variables.

Types of alcoholics: concurrent and predictive validity of some common classification schemes.

This study evaluated the discriminative power and predictive validity of five common typological schemes used to classify alcoholics for theoretical or clinical purposes. A heterogenous sample of 321 alcoholics was classified according to primary vs secondary alcoholism, parental alcoholism, Fellinek's gamma-delta distinction, gender, and subtypes derived from MMPI profiles. A prospective longitudinal cohort design was employed to compare the relative ability of these typologies to differentiate alcoholics according to natural history, alcohol-related consequences, response to treatment, and post-treatment adjustment. The findings indicate that while 'one-dimensional' typologies discriminate subgroups in terms of etiological variables, presenting symptoms, and drinking patterns, none of the classification systems emerges as a strong predictor of outcome status. In addition, these typologies do not discriminate well with respect to the alcoholic's drinking patterns and presenting symptoms, except in areas closely connected with the model (e.g. alcoholics with antisocial personality (ASP) indicate more social problems related to alcohol use than do primary alcoholics). Because there is a great deal of overlap among certain subtypes identified within different typological models (e.g. alcoholics with primary ASP tended to have a positive family history and a gamma pattern of impaired control), we hypothesize that empirical clustering techniques that search for naturally occurring commonalities among alcoholics may be a better way to identify homogeneous subtypes.

Neuropsychological factors in individuals at high risk for alcoholism.

It has been postulated that deficits in certain areas of cognitive functioning among children of alcoholics may contribute to their increased risk for developing alcoholism and other substance abuse disorders. In this chapter, the recent evidence for this hypothesis is critically reviewed. Studies citing differences in cognitive functioning between persons at high risk versus those at low risk for alcoholism are presented as well as those studies that have failed to demonstrate differences in cognitive abilities. On balance, the evidence in support of variations in cognitive abilities at risk factors for the development of alcoholism is not strong. The equivocal nature of the literature may be due to a variety of issues related to the design of studies examining risk factors for alcoholism, to the variability of definitions of family history positive used, to the failure to adequately control potentially confounding subject variables, and to the improper analysis of data. Recommendations are made for future studies examining neuropsychological functioning in "at risk" samples.

Gender comparison of antisocial personality disorder and depression in alcoholism.

This study compared male and female alcoholics in terms of family history of alcoholism, Antisocial Personality (ASP), and depression on the course, consequences, and 1-year treatment outcome. The sample included 266 subjects (197 men and 69 women) who were hospitalized for treatment of alcoholism from three facilities in the greater Hartford area. Female alcoholics reported higher rates of alcoholism among their fathers than men across all diagnostic categories. Both male and female alcoholics who were diagnosed as having ASP reported higher alcoholism among their fathers than those with depression or no other diagnoses. Male alcoholics reported a longer duration of alcohol abuse and a higher number of lifetime alcohol-related problems than women. Subjects with ASP reported more childhood behavior problems, higher levels of alcohol consumption, and more affective and physical disturbances in the month prior to hospitalization whereas no gender differences were found on those variables. ASP alcoholics reported poorer 1-year treatment outcomes than non-ASP alcoholics. Males who were diagnosed as having depression tended to relapse, although the diagnosis of depression tended to modify the rate of relapse among women. The rate of depression was higher among women than men at the 1-year follow-up.

Suicide attempts and alcoholism.

This study examined the association among suicide attempts, parental alcoholism, psychopathology and drinking history in a sample of hospitalized alcoholics. Suicide attempters were found to have multiple psychiatric diagnoses (e.g., depression, antisocial personality disorder and substance abuse) and more severe psychiatric symptoms than nonattempters. Alcoholic suicide attempters also tended to have a parental history of alcoholism and began abusing alcohol at an early age. Alcohol abuse symptoms during the month before, and 6 months before, the current hospitalization were generally similar for suicide attempters and nonattempters. Clinical implications of the findings are discussed.

Effects of retesting with the Beck and Zung depression scales in alcoholics.

The present study assessed the presence of testing effects arising from the repeated administration of both the Beck and Zung depression scales to a group of 60 inpatient alcoholics. Thirty-seven men and 23 women were randomly assigned to one of three groups and administered the depression scales on one, two or three occasions, in successive weeks of treatment. Although the between group comparisons of initial test administration did not indicate a true change in depression, a within group comparison of initial with subsequent test administrations indicated a clear improvement in depression scores on both scales. Apparently the result of the reactive effects of testing, the within group differences could easily mislead a researcher into believing depression was alleviated when in fact it was not. This sizeable testing effect has obvious implications for studies which repeatedly assess depression.

Effect of major depression and antisocial personality on alcoholism: course and motivational patterns.

Major depression and antisocial personality are two diagnoses often associated with alcoholism. The relationship of these two diagnoses to the course of alcoholism and on the motivation for alcohol use was examined in a sample of 321 persons receiving inpatient treatment for alcoholism. Major depression did not alter the course of alcoholism in either men or women. However, patients with a history of major depression more frequently reported drinking to relieve symptoms related to depression than patients without a history of major depression. Patients with antisocial personality had an earlier onset of alcohol-related problems than patients without antisocial personality. The motivational patterns for drinking did not distinguish patients with antisocial personality from patients without antisocial personality. These findings indicate the etiological logical importance of antisocial personality for the development of alcoholism and highlight the patients' perception of depression as an explanation for their drinking.

Alcoholic typologies. A review of empirical evaluations of common classification schemes.

This chapter reviews literature examining two typological classifications of alcoholism: typologies derived empirically by employing multivariate statistical techniques and typological classification schemes formulated from theoretical frameworks. Most of the empirical classifications were based on personality measures such as the MMPI, 16PF, and others. Examinations of theoretically based typologies included gender, psychopathology, and family history. The usefulness and limitations of these typological approaches are discussed.

Psychopathology in hospitalized alcoholics.

This study utilized the DSM-III criteria and the National Institute of Mental Health Diagnostic Interview Schedule to assess the prevalence of lifetime psychopathology among hospitalized alcoholics. Antisocial personality (ASP) and substance-use disorder were common psychopathologies among male alcoholics and major depression and phobia were common among female alcoholics. The onset of most psychopathologies preceded the abuse of alcohol among women. In men, however, with the exception of ASP and panic disorder, the onset of psychopathology was subsequent to that of alcohol abuse and/or dependence. Diagnoses of ASP and substance abuse were characterized by early onset of regular intoxication and alcohol abuse. Gender and the presence of specific psychopathology appeared to modify the course and symptom picture of alcoholism. In general, alcoholic women showed a later onset of regular intoxication and a more rapid progression to alcohol abuse and dependence than alcoholic men.

Discriminative control of alcoholics' drinking by the drinking situation.

Implicit in what has come to be called the loss of control concept is the notion that the environment, or the context within which drinking occurs, exerts little influence on the quantity of alcohol consumed by an alcoholic. In contrast, recent formulations of the alcohol dependence syndrome have argued that dependence arises from an interaction among personality, pharmacological and contextual variables. The present study investigated the relationship between contextual factors and alcohol consumption in 231 men and 90 women alcoholics. Self-report questionnaire data were obtained describing social pressures to drink more or less than usual, and the usual quantity of drinking in a variety of situations (e.g., at home alone, in bars or in family settings). The findings indicate clear differences in the quantities that alcoholics drink when alone, with friends or with family. Even the dependent drinker is apparently able to discriminate the relative quantity of drinking that will be socially sanctioned in a given situation and modify consumption accordingly. In situations in which constraints are absent or minimal (e.g., alone), drinking tends to be greater than in situations in which social controls are more pronounced (e.g., with friends and family).