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Is alcohol consumption irrelevant to outcome in anxiety and depression?

Published online by Cambridge University Press:  02 January 2018

John Bailey
Affiliation:
Centre for Mental Health and Society, Bangor University, UK. Email: j.bailey@bangor.ac.uk
Rob Poole
Affiliation:
Centre for Mental Health and Society, Bangor University
Susan Ruben
Affiliation:
Betsi Cadwaladr University NHS Trust, North Wales
Catherine A. Robinson
Affiliation:
Centre for Mental Health and Society, Bangor University, UK
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Abstract

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Copyright © Royal College of Psychiatrists, 2012 

Boschloo and colleagues Reference Boschloo, Vogelzangs, van den Brink, Smit, Veltman and Beekman1 report that DSM-IV alcohol abuse is not a risk factor for unfavourable outcome in depression and anxiety disorders. This finding, which ostensibly conflicts with clinical experience, could easily be misunderstood to imply that non-dependent alcohol use is irrelevant in these disorders. We do not believe this is a true finding of the study. The paper addresses DSM-IV alcohol use disorder diagnosis at baseline as a risk factor for poor outcome. It does not address continuing alcohol abuse and its effects on depression and anxiety. Latest alcohol consumption statistics show that a substantial proportion of the population drink alcohol heavily. In England, the latest estimates are that 26% of men and 17% of women over the age of 16 drink at levels that are hazardous or harmful to health. 2 Clearly, only a small proportion of these receive a diagnosis of alcohol use disorder and there is no reason to believe that the situation in The Netherlands is radically different. It would be expected that a significant proportion of the sample with no alcohol use disorder diagnosis would be drinking alcohol at hazardous or harmful levels. Alcohol use disorder is therefore a poor marker for alcohol consumption. Alcohol use disorder diagnosis cannot have an effect on the course of depressive or anxiety disorders as it is a theoretical construct. It is alcohol consumption that has an effect. The current data are extracted from a larger study with different aims Reference Penninx, Beekman, Smit, Zitman, Nolen and Spinhoven3,Reference Van Der Veen, Van Der Meer and Penninx4 and contain a number of flaws when used to examine the effects of alcohol on depression and anxiety. There are no indications of levels of alcohol consumption other than alcohol use disorder diagnosis and there are no data on alcohol diagnosis at follow-up. There is no information about what treatments the sample patients received, although this is likely to have included advice to reduce alcohol consumption. Unsurprisingly, the study demonstrates that those with the poorest depression and anxiety outcomes are those with a baseline diagnosis of alcohol dependence, with a stronger effect with increasing severity of disorder. That is, those patients least likely to have reduced their alcohol consumption during the study had the poorest outcomes. There is a puzzling finding in relation to severity of alcohol diagnosis: there are more patients in the sample with the more severe diagnosis of alcohol dependence than with the less severe diagnosis of alcohol abuse. The diagnostic criteria for alcohol abuse are concerned largely with social dysfunction, whereas those for alcohol dependence are concerned with physical dependence and social dysfunction. It may be that the gap between the onset of moderate social dysfunction and the onset of physical dependence or severe social dysfunction (as determined by the diagnostic criteria) represents a small part of the deterioration resulting from sustained heavy drinking, and therefore is a poor indicator of population harmful drinking. The paper does convincingly suggest that severe alcohol dependence at baseline is a risk factor for poor outcome in anxiety and depression. It does not demonstrate that continued drinking in other groups is irrelevant to outcome.

References

1 Boschloo, L, Vogelzangs, N, van den Brink, W, Smit, JH, Veltman, DJ, Beekman, ATF, et al. Alcohol use disorders and the course of depressive and anxiety disorders. Br J Psychiatry 2012; 200: 476–84.CrossRefGoogle ScholarPubMed
2 Health and Social Care Information Centre. Statistics on Alcohol: England, 2012. Health and Social Care Information Centre, 2012.Google Scholar
3 Penninx, BWJH, Beekman, ATF, Smit, JH, Zitman, FG, Nolen, WA, Spinhoven, P, et al. The Netherlands Study of Depression and Anxiety (NESDA): rationale, objectives and methods. Int J Methods Psychiatr Res 2008; 17: 121–40.CrossRefGoogle ScholarPubMed
4 Van Der Veen, WJ, Van Der Meer, K, Penninx, BW. Screening for depression and anxiety: correlates of non-response and cohort attrition in the Netherlands Study of Depression and Anxiety (NESDA). Int J Methods Psychiatr Res 2009; 18: 229–39.Google Scholar
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