alcohol in society/ Discussion
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PAMELA KORSMEYER ERIC WISH
n
EPIDEMIOLOGY OF ALCOHOL USE DISORDERS. Epidemiology is the study of the distribution and determinants of health outcomes in a population. Distribution refers to the incidence and prevalence of health outcomes in the population as a whole or within subgroups of the population, as well as to trends over time in health outcomes. Determinants are factors that pre- dict an increased risk for the onset or persistence of health outcomes. Unlike other branches of medi- cine, epidemiology focuses on factors affecting dis- ease in a particular population or larger community. A ‘‘population of interest’’ may be a group defined by age, sex, or race and ethnicity, or it may be groups of patients in treatment facilities. A ‘‘com- munity of interest’’ may comprise household resi- dents in a particular geographic area.
Of concern here is the epidemiology of alcohol abuse and dependence (referred to together as ‘‘alco- hol use disorders’’). The definition of alcohol use disorders used throughout will refer to the DSM- IV definitions of the disorders. First, information on historical trends in alcohol consumption will be reviewed. As alcohol consumption is a neces- sary, but not sufficient, cause of alcohol abuse and dependence, the study of alcohol consumption can provide clues about trends in abuse and dependence in time periods for which diagnostic information is unavailable. Second, the design and results of major U.S. surveys in which the preva- lence of alcohol abuse and dependence has been estimated will be analyzed. Third, the course of alcohol disorders will be examined by looking at onset, duration, recovery, and treatment rates. Finally, there will be an overview of major risk factors for alcohol abuse and dependence.
HISTORICAL TRENDS IN ALCOHOL
CONSUMPTION
Long-term historical information on U.S. alcohol consumption is available through per capita alcohol consumption statistics derived from sales figures. These statistics do not reflect the prevalence of
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alcohol use disorders, but the statistics do provide information from the 1700s to the present on alcohol consumption, a necessary condition for the development of alcohol dependence or abuse. However, these statistics only reflect alcohol sales, not the totality of alcohol consumption (especially during the period of Prohibition). Despite this limitation, studies of long-term trends in alcohol sales provide a historical picture of alcohol con- sumption in the United States, and this can give valuable clues regarding trends in alcohol abuse and dependence before specific diagnostic criteria were established.
These figures show drinking levels in the U.S. varied greatly over time (Lender & Martin, 1982). Per capita consumption levels ranged from extra- ordinarily high levels during the U.S. colonial period (from an estimated 5.8 gallons per year per capita in 1790 to 7.1 gallons in 1830) to very low levels before and during Prohibition, which began in 1919 (from an estimated 1.96 gallons in 1916 to 0.97 gallons in 1934). Levels were high during the colonial era because water supplies were unsafe, so
that even children drank alcohol. Figure 1 shows the estimated per capita alcohol consumption from the end of Prohibition in 1933 through 2005. From 1935 until 1982, per capita alcohol con- sumption increased steadily to a peak of nearly 2.8 gallons of ethanol per year in 1982 (Lakins et al., 2007). Since then, consumption has declined, leveling off at about 2.2 gallons of ethanol per year in 1993, and remaining at around that level until 2005, with a slight increase from 1999 to 2005. These data are generally consistent with liver cirrho- sis mortality statistics, which show similar variations over time (Yoon et al., 2006).
Surveys are another source of alcohol con- sumption information. These surveys ask a repre- sentative sample of individuals to self-report on alcohol consumption. The advantage of surveys over alcohol sales data is that subgroup variations in alcohol consumption can be examined. The main disadvantages are that yearly information is often not available and individuals can underreport their alcohol consumption. Several national alcohol surveys have focused on direct questions about
1935
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Figure 1. Total per capita ethanol consumption, United States, 1935–2005. (Source: Lakins et al., 2007.) ILLUSTRATION BY GGS
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consumption and nondiagnostic scales of alcohol- related problems. Conjoint analysis of several of these surveys showed that the lifetime and current prevalence of multiple alcohol-related problems increased in the U.S. general population from 1967 to 1984 (Hasin et al., 1990), but decreased from 1985 to 1995 (Greenfield et al., 2000; Hil- ton, 1987). The consistency of these findings lends credence to both sales-based and survey data.
PSYCHIATRIC EPIDEMIOLOGIC
SURVEYS: AN OVERVIEW
Unlike alcohol consumption, which in itself is not a disorder, alcohol abuse and dependence are specific diagnoses defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV). The DSM-IV stipulates that individuals must exhibit a maladaptive pattern of alcohol consump- tion accompanied by specific criteria. Most avail- able information on the prevalence of alcohol use disorders in the general U.S. population comes from large-scale psychiatric epidemiologic surveys conducted after the 1970s. Prior to the 1970s, large-scale epidemiologic studies did not address alcohol use disorders and generally used a very different methodology. In the mid- and late- 1970s, diagnostic methods in psychiatry changed, allowing the use of specific diagnostic criteria for disorders including alcohol use disorders (Spitzer
et al., 1978). This advance in methodology led to five major large-scale psychiatric epidemiologic stud- ies based on specific diagnostic criteria: the Epide- miologic Catchment Area Survey (ECA), the National Comorbidity Survey (NCS), the National Longitu- dinal Alcohol Epidemiological Survey (NLAES), the National Comorbidity Study Replication (NCS-R), and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Table 1 shows numerous features of each study.
PSYCHIATRIC EPIDEMIOLOGIC SURVEYS:
DESCRIPTIONS OF EACH STUDY
In these surveys, large sample sizes and a wide geographic distribution of data collection has pre- cluded the use of clinicians as interviewers. There- fore, structured diagnostic interviews were devel- oped that could be administered by nonclinicians to collect data on symptoms and criteria of psychi- atric disorders, including alcohol use disorders. Table 2 shows the diagnostic assessment proce- dures used in the five studies. Each interview form has distinctive structural features, and some, such as the NCS-R, appear to have influenced the rates of alcohol dependence obtained.
Epidemiologic Catchment Area Study (ECA). The ECA, the earliest of the three major third- generation studies, was conducted between 1980
Feature
Sponsoring institution Years of data collection Sample size Response rate (approximate) Sample
Sampling method
Individuals surveyed
Age range Field work conducted by:
Follow-up component
ECA
NIMH 1980–1984 20,219 77.60% 5 U.S. communities Probability, block sampling and oversampling in some sites Household� institutional residents 18 and older Independent academic researchers at the five sites 1-year follow-up at all sites (N�10,167), ongoing 13-year follow-up at the Baltimore site
NCS
NIMH 1990–1992 8,098 82.60% U.S. general population Probability Household and college residents 15–54 Survey Research Institute, University of Michigan 10-year follow-up (N�4,375)
NLAES
NIAAA 1991–1992 42,862 89.20% U.S. general population Probability,
oversampling for minorities and young adults
Household residents 18 and older U.S. Bureau of the Census None
NCS-R
WHO 2001–2003 9,282 70.90% U.S. general population Probability Household and college residents 18 and older Survey Research Institute, University of Michigan None
NESARC
NIAAA 2001–2002 43,098 81.00% U.S. general population Probability, oversampling for minorities and young adults Household and group quarters residents 18 and older U.S. Bureau of the Census
1-year follow-up, N�34,653
Table 1. Design features of the five U.S. third-generation psychiatric epidemiological studies. ILLUSTRATION BY GGS INFORMATION
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and 1984. One explicit purpose of this study was the assessment of psychiatric disorders according to the then-new DSM-III nomenclature. Unlike the remaining surveys discussed below, the ECA sur- veyed five communities, located in New Haven, Connecticut, Los Angeles, California, Baltimore, Maryland, St. Louis, Missouri, and Durham, North Carolina. Despite the sample’s geographic distribu- tion, weights were eventually derived to estimate national rates of alcohol use disorders (as well as other psychiatric disorders). The study’s interview, the Diagnostic Interview Schedule (DIS), was developed specifically for the ECA.
The National Comorbidity Study (NCS). The NCS was designed to provide data on the comor- bidity of alcohol and other psychiatric disorders based on a full national sample. With the publica- tion of the revision of DSM-III in 1987, general population data using the more recent DSM-III-R diagnostic criteria were needed. The interview, the University of Michigan version of the Composite International Diagnostic Interview (UM-CIDI), was developed for this survey, with various features that differentiated it from other structured diag- nostic interviews (see Table 2). Another difference between the NCS and the ECA interviews was the collection of risk factor data in the NCS to offer explanations for the etiology of disorders. Test- retest studies (which measure whether two inde- pendent evaluators produce the same results from a given respondent) for alcohol disorders and drug disorders in the CIDI indicated good reliability for these diagnoses (Wittchen, 1994).
The National Longitudinal Alcohol Epide- miologic Survey (NLAES). The NLAES, the first national survey with a primary focus on DSM-defined alcohol use disorders, was conducted in 1992. The survey aims were to provide accurate estimates of alcohol abuse and dependence, associ- ated physical and mental disabilities, treatment uti- lization, information on risk factors for substance use disorders, and the economic impact of these disorders. This required a large sample and reliable diagnostic measures. As Table 1 demonstrates, the sample was very large, exceeding 40,000 people. The diagnostic interview developed for the NLAES was the Alcohol Use Disorders and Associated Dis- abilities Interview Schedule, or AUDADIS (see
Grant & Hasin, 1992). In the AUDADIS, alcohol dependence is not diagnosed unless symptoms cluster together chronologically. Although the NLAES was conducted prior to the publication of DSM-IV, the AUDADIS obtained the necessary information to make alcohol, drug, and psychiatric diagnoses according to DSM-IV criteria. The AUDADIS diagnoses were also subjected to test- retest reliability studies, and the results indicated good to excellent reliability for current and past alcohol disorders, and adequate to good reliability for drug disorder symptoms and diagnoses (Grant et al., 1995).
The National Epidemiologic Survey on Alco- hol and Related Conditions (NESARC). From 2001 to 2002, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) spon- sored a survey whose sample design was similar to the NLAES, using a measurement instrument updated for DSM-IV (AUDADIS-IV). The NESARC included a national sample of over 43,000 respond- ents aged 18 and older, who were assessed for a wide range of psychiatric disorders, including alco- hol disorders. Respondents were followed for three years and reassessed for psychiatric disorders from 2004 to 2005. Longitudinal studies are valuable in epidemiology because factors predicting the onset of disorder (as opposed to the prevalence of disorder) can be directly estimated without the potential for recall bias. Similar to the prior version of the AUDADIS, the updated version documented good to excellent test-retest reliability of alcohol diagno- ses (Ruan et al., 2008).
National Comorbidity Study Replication (NCS-R). Part of a survey of 26 countries con- ducted by the World Mental Health (WMH) Sur- vey Initiative, the NCS-R was conducted between 2001 and 2003. The NCS-R strived to study trends over time in psychiatric illness, and to update the prevalence of psychiatric disorders in accordance with the publication of the DSM-IV. Interview and study design features are similar enough to those of the NCS to make comparisons of the studies legitimate. An exception to this is the introduction of a new ‘‘skip feature’’ that elimi- nated all questions on alcohol and drug depen- dence among respondents that never met criteria for alcohol or drug abuse, respectively. A clinical
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reappraisal study was conducted using a subset of the NCS-R respondents; with the results showing adequate sensitivity for alcohol abuse but low sen- sitivity for alcohol dependence (63.1% and 43.1%, respectively), and excellent specificity (98.1% and 99.9%, respectively) (Kessler & Merikangas, 2004). Low sensitivity for alcohol dependence was a marked departure from the normally excellent psy- chometric properties of alcohol dependence meas- ured in other major surveys, and this difference was likely due to the aforementioned skip over alcohol and drug dependence questions.
PREVALENCE OF ALCOHOL USE DISORDERS:
EVIDENCE FROM PSYCHIATRIC
EPIDEMIOLOGIC SURVEYS
Prevalence refers to the proportion of the popula- tion with alcohol abuse OR dependence at a given moment or period in time. Prevalence estimates are used in describing the disease burden on a popula- tion. Table 1 details the prevalence of alcohol abuse and dependence in the five major epidemiologic surveys, which estimated both current and lifetime alcohol use disorders. While estimates differ due to variations in the measurement and definition of ‘‘current disorder’’ and the design of the surveys (see Tables 2 and 3), these studies, ‘‘taken together,’’ provide a comprehensive assessment of the preva- lence of alcohol abuse and dependence in the U.S. population.
The prevalence of current alcohol abuse ranges from 1.9 percent in the ECA to 4.7 percent in the NESARC. Current alcohol dependence ranges from 1.3 percent in the NCS-R to 7.2 percent in
the NCS. Overall, the prevalence of any current alcohol disorder ranges from approximately 4 per- cent to 10 percent. On a lifetime basis, estimates across surveys vary more widely. The lifetime prev- alence of alcohol abuse ranges from 5.6 percent in the ECA to 17.8 percent in the NESARC, while alcohol dependence ranges from 5.4 percent in the NCS-R to 14.1 percent in the NCS. Together, these estimates indicate alcohol abuse and depen- dence are relatively common disorders compared to other psychiatric disorders and other chronic dis- eases in the population.
Because the NLAES and the NESARC used the same instrument in each survey, it is possible to examine trends over time (see Table 3). Overall, the prevalence of any current alcohol disorder increased from 7.4 percent to 8.5 percent, due mostly to an increase in the prevalence of alcohol abuse (3% to 4.7%). The prevalence of alcohol dependence decreased slightly during this period (4.4% to 3.8%). The prevalence of any lifetime alcohol disorder increased from 18.2 percent to 30.3 percent between 1991 and 1992, again due mostly to an increase in the prevalence of lifetime alcohol abuse (4.9% to 17.8%), for alcohol dependence decreased slightly (13.3% to 12.5%). Further discussion of these trends is provided by Grant and colleagues (2004).
LONGITUDINAL COURSE OF A DISORDER:
ONSET, COURSE, AND RECOVERY
National surveys and longitudinal studies in both clinical and community samples have documented the course of alcohol disorders. Longitudinal stud- ies have several advantages over cross-sectional studies in assessing the course of alcohol disorders, including minimal bias due to recall and selective mortality. However, longitudinal studies are often conducted among specialized samples, such as indi- viduals in treatment. In general, longitudinal and cross-sectional studies concur regarding the course of alcohol use disorders.
Initiation of alcohol consumption often occurs during adolescence. Onset of alcohol abuse and dependence is most likely among individuals aged 18 to 29, although 15 percent of alcohol depen- dence cases begin before age 18 (Hingston et al., 2006). While alcohol abuse was once believed to be a prodromal form of alcohol dependence, evidence now suggests that over a third of those with alcohol
Survey
Disorder ECA NCS NLAES NCS-R NESARC
Current*
Any Alcohol Use Disorder Alcohol Abuse Alcohol Dependence
Lifetime
Any Alcohol Use Disorder Alcohol Abuse Alcohol Dependence
4.8 1.9 2.8
13.5 5.6 7.9
9.7 2.5 7.2
23.5 9.4
14.1
7.4 3
4.4
18.2 4.9
13.3
4.4* 3.1 1.3*
18.6* 13.2 5.4*
8.5 4.7 3.8
30.3 17.8 12.5
*Dependence not assessed in those without abuse
Table 3. Prevalence of current and lifetime alcohol disorders
in five general population surveys. ILLUSTRATION BY GGS
INFORMATION SERVICES. GALE, CENGAGE LEARNING
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dependence do not meet abuse criteria (Hasin et al., 2004). In addition, longitudinal studies sug- gest that many individuals with alcohol abuse do not develop alcohol dependence (Hasin et al., 1990; Schuckit et al., 2005). The duration of alco- hol disorders is often, but not always, chronic, with an estimated mean of nearly four years for alcohol dependence (Hasin et al., 2007).
Often, alcohol abuse and dependence are not lifelong conditions. Indeed, a high rate of recovery has been documented in general population sam- ples, even among individuals who have never sought treatment. Studies of the general popula- tion also show that a high proportion of recovered individuals return to moderate drinking as opposed to abstinence (Tucker, 2003; Watson & Sher, 1998). Data from the NESARC indicated that approximately 75 percent of individuals diagnosed with alcohol dependence at some point in the past did not have a current (i.e., past year) diagnosis, but that only about 20 percent of these individuals were abstinent from alcohol (Dawson et al., 2004). Thus, the transition to adulthood represents a key developmental phase in which alcohol disorders often remit, in a process termed ‘‘maturing out’’ (Bachman et al., 2002; Dawson et al., 2006). Major predictors of recovery include key lifestyle components, such as employment, marriage, and childbirth. Whether or not these factors have a causal influence on recovery or reflect common factors underlying the positive lifestyle components and the recovery remains unknown.
Despite substantial progress in the develop- ment of treatments for alcohol disorders, only about one-fifth of those individuals with an alcohol disorder seek treatment for the condition during their lifetime (Cohen et al., 2007). Further, the delay from onset of disorder to treatment is typi- cally eight to ten years (Wang et al., 2005). Finally, in contrast to sharp increases in treatment utiliza- tion for disorders such as depression between 1990 and 2003, a corresponding increase in the propor- tion of individuals seeking treatment for an alcohol disorder did not occur during this period (Kessler et al., 2005).
DEMOGRAPHIC CHARACTERISTICS
AND OTHER ESTABLISHED RISK FACTORS
FOR ALCOHOL USE DISORDERS
The term risk factor refers to a characteristic of an individual or community that influences disease
risk in a population. Risk factor epidemiology is an important method used to characterize factors that influence vulnerability to alcohol abuse and dependence, and to identify subpopulations for greater intervention and prevention efforts.
Demographic Risk Factors. Alcohol use disor- ders are not distributed randomly in the popula- tion. On the contrary, certain demographic groups exhibit a higher prevalence of alcohol use disorders than others. Gender is a well-documented risk fac- tor, for example. In particular, men are more likely to have alcohol use disorders than women, although evidence suggests gender differences in the prevalence of disorder have decreased over time (Keyes, Grant, & Hasin, 2007). As noted above, age is strongly related to the development of alco- hol use disorders, and alcohol disorders are often exhibited in young adulthood.
Socioeconomic status is inversely related to alcohol dependence, so that individuals in lower socioeconomic groups have a higher prevalence of disorder. Alcohol abuse, conversely, is more com- mon among individuals with higher income and educational attainment (Van Oers et al., 1999). Finally, the prevalence of alcohol use disorders varies according to a person’s self-described race or ethnic group. Of the largest such groups tracked in U.S. surveys, most surveys found that Native Americans and non-Hispanic whites have the high- est prevalence of alcohol disorders, while individu- als of Asian descent typically have the lowest prev- alence (Huang et al., 2006).
Environmental factors. A particular substance must be available in the environment for individuals to be at risk for the development of disorders involv- ing that substance. In Western societies, competing forces influence alcohol availability. Public health, moral or religious, ‘‘grassroots,’’ and governmental organizations attempt to reduce availability and con- sumption by influencing public policy and laws, while the alcoholic beverage industry attempts to increase consumption through advertising and other means. Widespread social attitudes toward alcohol use, as well as political events, also influence avail- ability and consumption, thereby influencing the risk of alcohol use disorders.
Other external environmental factors include home and family life. Poor parental monitoring
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and the modeling of heavy alcohol use contribute
to the likelihood of adolescent alcohol initiation
and binge drinking, although these factors may be
mediators within the relationship between parental
alcohol problems and adolescent alcohol use (Haw-
kins, Catalano, & Miller, 1992; Ellis, Zucker, &
Fitzgerald, 1997; Repetti, Taylor, & Seeman,
2002). Peer influence and stressful life events are
also strongly associated with adolescent alcohol
abuse, while religiosity is a well-replicated protec-
tive factor (Kendler et al., 1997, Kendler et al.,
2000; Walden et al., 2004; Dube et al., 2003).
Individual Risk Factors. Important risk factors
for the development of alcohol disorders also exist
within the individual, including positive alcohol
expectancies and motivations for drinking. These
beliefs and motivations can have roots in family and
peer influences, but they are characteristics of the
individual’s internal environment. Individuals with
certain personality traits, such as novelty or sensa-
tion seeking (Zuckerman & Kuhlman, 2000), may
be more likely to experiment with heavy drinking,
while co-occurring disorders associated with impul-
sivity and risk taking, such as conduct disorder and
antisocial personality disorder, have been shown to
predict the development of an alcohol disorder
(Cloninger, Sigvardsson, & Bohman, 1988; Sher
& Trull, 1994). Further, early onset of alcohol
consumption is associated with a higher risk of
alcohol disorder onset (Grant & Dawson, 1997;
Grant et al., 2006), although evidence suggests
that any early deviant behavior, including but not
limited to alcohol consumption, is associated with
later onset of an alcohol disorder (Kuperman et al.,
2005; McGue & Iacono, 2005; King & Chassin,
2007). Thus, it is unclear whether early onset of
drinking is a specific risk factor for alcohol disor-
ders or a risk factor for a general category of exter-
nalizing behaviors.
Genetic factors are also important in the devel- opment of an alcohol disorder. Alcohol disorders are known to be familial (Cotton, 1979; Bierut et al., 1998), and twin studies of alcohol dependence show estimates of heritability (i.e., the proportion of risk attributable to genetics) of 50 percent to 60 percent (Klender et al., 2003; Heath, 1995; Rhee et al., 2003). The Collaborative Study on the
Genetics of Alcoholism (COGA), a multisite family study of alcohol-dependent patients and their rela-
tives, has contributed greatly to current knowledge
of the genetic epidemiology of alcohol disorders,
as have a series of case-control and family studies
at Yale University and the University of Con-
necticut (Luo et al., 2006; Kaufman et al.,
2007). In addition, linkage and association stud-
ies involving fine gene mapping have identified
specific genes and alleles associated with alcohol
dependence and related phenotypes through var-
ious mechanisms.
CONCLUSION
The field of epidemiology has facilitated estimates
of the incidence and prevalence of alcohol use dis-
orders and helped identify important risk factors
for the onset and persistence of the disorders over
time. Issues concerning major epidemiologic sur-
veys include reliance on the self-reporting of prob-
lem behaviors and recall bias, which can affect life-
time estimates. Despite these limitations, however,
epidemiologic studies present the most valid national
picture of alcohol use disorders, their course, and
factors associated with their occurrence. Thus, these
findings play a vital role in advancing knowledge of
alcohol use disorders in the general population.
See also Alcohol: Chemistry and Pharmacology; Alcohol: History of Drinking; Alcoholism: Abstinence versus Controlled Drinking; Antisocial Personality Disor- der; Diagnosis of Substance Use Disorders: Diag- nostic Criteria; Diagnostic and Statistical Manual (DSM); Gender and Complications of Substance Abuse; Intimate Partner Violence and Alcohol/ Substance Use; Models of Alcoholism and Drug Abuse; Prohibition of Alcohol; Research: Develop- ing Medications to Treat Substance Abuse and Dependence; Risk Factors for Substance Use, Abuse, and Dependence: An Overview; Treatment: An Overview of Alcohol Abuse/Dependence.
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KATHERINE M. KEYES DEBORAH S. HASIN
n
EPIDEMIOLOGY OF DRUG ABUSE. Epidemiology can be thought of as the cornerstone of public health research. It is a branch of biomed- ical science that deals with measuring the occur- rence and frequency of a disease in a population, as well as identifying the causes and mechanisms. Evi- dence gathered in epidemiologic investigations is used to inform future prevention efforts and man- agement of the disease. Unlike general clinical practice, epidemiology focuses on populations at risk and their subgroups rather than individuals, although individual clinical experiences can be guided by epidemiology. The epidemiology of drug abuse is concerned with describing the distri- bution of drug use and its associated disorders. To
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