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Authors' reply

Published online by Cambridge University Press:  02 January 2018

Lynn Boschloo
Affiliation:
Department of Psychiatry and EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, and Department of Psychiatry, University Medical Centre, Hanzeplein 1, Groningen, The Netherlands; Email: l.boschloo@umcg.nl
Nicole Vogelzangs
Affiliation:
Department of Psychiatry and EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam
Wim van den Brink
Affiliation:
Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam
Johannes H. Smit
Affiliation:
Department of Psychiatry and EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam
Dick J. Veltman
Affiliation:
Department of Psychiatry, VU University Medical Centre, Amsterdam
Aartjan T. F. Beekman
Affiliation:
Department of Psychiatry and EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam
Brenda W. J. H. Penninx
Affiliation:
Department of Psychiatry and EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, Department of Psychiatry, University Medical Centre, Groningen, and Department of Psychiatry, Leiden University Medical Centre, The Netherlands
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Abstract

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Columns
Copyright
Copyright © Royal College of Psychiatrists, 2012 

We appreciate Bailey et al's interest in our study Reference Boschloo, Vogelzangs, Van den Brink, Smit, Veltman and Beekman1 and respond to their comments regarding the found differential effects of alcohol dependence v. alcohol abuse and alcohol consumption.

It is evident that heavy alcohol consumption has a major impact on public health because of its negative consequences on the onset and course of various diseases. 2 However, this does not necessarily imply that the level of alcohol consumption is also causally related to the onset and persistence of psychopathology such as depression and anxiety. For example, Haynes et al Reference Haynes, Farrell, Singleton, Meltzer, Araya, Lewis and Wiles3 showed that heavy alcohol consumption was not a risk factor for the onset of depression and anxiety in a national sample of adults in Great Britain. Furthermore, additional analyses in our sample showed that neither heavy alcohol consumption at baseline (odds ratio (OR) = 0.98, 95% CI 0.71–1.36) nor at 2-year follow-up (OR = 0.98, 95% CI 0.69–1.41) predicted the persistence of depression and anxiety.

In contrast, DSM-IV alcohol dependence has strong links with depression and anxiety. For example, previous epidemiological studies have demonstrated robust cross-sectional associations Reference Boschloo, Vogelzangs, Smit, Van den Brink, Veltman and Beekman4,Reference Hasin, Stinson, Ogburn and Grant5 and, in addition, our study showed that alcohol dependence at baseline was an important risk factor for the persistence of depression and anxiety during 2-year follow-up (OR = 1.69, 95% CI 1.04–2.75, adjusted for basic covariates). Reference Boschloo, Vogelzangs, Van den Brink, Smit, Veltman and Beekman1 Additional analyses further showed that this association remained significant after controlling for the possible effects of alcohol consumption (OR = 2.05, 95% CI 1.19–3.53, additionally adjusted for alcohol consumption). This indicates that impairments related to alcohol dependence, rather than consumption per se, have an effect on the course of depression and anxiety. Support for this hypothesis was also provided by our finding that persistence rates of depression and anxiety increased with the severity of alcohol dependence (i.e. number of alcohol dependence criteria). Reference Boschloo, Vogelzangs, Van den Brink, Smit, Veltman and Beekman1

Previous studies have raised the question whether DSM-IV alcohol abuse should be considered a genuine psychiatric disorder as it was characterised by low severity in the general population and showed limited reliability and validity (see Boschloo et al Reference Boschloo, Vogelzangs, Van den Brink, Smit, Veltman and Beekman1 for a discussion on this topic). This notion received further support by our finding that 95.7% of patients with alcohol abuse met only one of four abuse criteria. Reference Boschloo, Vogelzangs, Van den Brink, Smit, Veltman and Beekman1 Additional analyses showed that alcohol abuse was not related to impairments in daily functioning (assessed with the World Health Organization Disability Assessment Schedule II) and had a favourable course (remission rate after 2 years: 93.5%). Apparently, alcohol abuse is characterised by only minimal alcohol-related impairments, which may clarify our finding that it was not related to the persistence of depression and anxiety. Note that alcohol abuse in our sample of out-patients with depression or anxiety or in the general population might differ substantially from alcohol abuse in clinical samples of severe abusers with regard to associated levels of impairment.

Taken together, these findings emphasise the importance of severity indicators, rather than dichotomous diagnoses of alcohol dependence or abuse, in the assessment of alcohol problems. This is in line with the proposal of the DSM-5 Work Group to distinguish different levels of severity within the diagnosis of an alcohol use disorder (www.dsm5.org).

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 World Health Organization. Global Status Report on Alcohol and Health. WHO, 2011.Google Scholar
3 Haynes, JC, Farrell, M, Singleton, N, Meltzer, H, Araya, R, Lewis, G, Wiles, NJ. Alcohol consumption as a risk factor for anxiety and depression. Results from the longitudinal follow-up of the National Psychiatric Morbidity Survey. Br J Psychiatry 2005; 187: 544–51.CrossRefGoogle ScholarPubMed
4 Boschloo, L, Vogelzangs, N, Smit, JH, Van den Brink, W, Veltman, DJ, Beekman, AT, et al. Comorbidity and risk indicators for alcohol use disorders among persons with anxiety and/or depressive disorders: findings from the Netherlands Study of Depression and Anxiety (NESDA). J Affect Disord 2011; 131: 233–42.CrossRefGoogle Scholar
5 Hasin, DS, Stinson, FS, Ogburn, E, Grant, BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2007; 64: 830–42.CrossRefGoogle ScholarPubMed
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