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Alcohol consumption and later risk of hospitalization with psychiatric disorders: Prospective cohort study
Psychiatry Research 2011, Volume 187, pages 214–219
The potential effects of alcohol intake upon the risk of psychiatric disorders have not often been investigated. The purpose of this study was to investigate, in a population sample, the association between self-reported amount of alcohol intake and the later risk of being registered in a Danish hospital with a psychiatric disorder. The prospective cohort study, the Copenhagen City Heart Study (n = 18,146), was used, containing three updated sets of alcohol intake and lifestyle covariates and up to 26 years follow-up. Alcohol intake was measured by self-report while psychiatric disorders were measured through registers. For women, the overall pattern showed that drinking above the sensible limits increased the risk of psychiatric disorders in general, especially for anxiety disorders where women drinking above the sensible drinking limits had a risk of 2.00 (confidence interval: 1.31–3.04) compared to women drinking below the sensible drinking limits. For men, the risk functions were slightly U-shaped; thus, a weekly low or moderate alcohol intake seemed to have a protective effect towards developing psychiatric disorders. The findings suggest sex differences in the association between alcohol consumption and risk of psychiatric disorders.
Keywords: Epidemiology, Prospective study, Alcohol drinking, Mood disorders, Psychotic disorders, Anxiety disorders, Personality disorders.
Denmark and several other countries have sensible drinking limits of 14 and 21 drinks per week for women and men, respectively (Webster-Harrison et al, 2001 and Mørch et al, 2005). These limits are primarily based on the risk of alcohol-related physical morbidity and mortality, but although 14 and 21 drinks per week may be a large amount of alcohol in relation to the physical influences of alcohol on the body, it does not necessarily affect social and mental functioning, and results concerning the relationship between alcohol intake and risk of psychiatric disorders have not been consistent (Hartka et al, 1991, Lipton, 1994, Schutte et al, 1995, Patten and Charney, 1998, Graham and Schmidt, 1999, Dixit and Crum, 2000, Rodgers et al, 2000, Alati et al, 2005, and Graham et al, 2007). In addition, due to lack of longitudinal studies, the causality of this potential association is unknown. Therefore prospective studies in which information on alcohol use is collected before development of psychiatric disorders are needed to provide relevant evidence. However, such studies have not been conducted.
Exposure to alcohol is a necessary factor for the development of alcohol use disorders (AUD) and it has been shown that the risk of AUD increases dose-dependently with increased alcohol intake ( Flensborg-Madsen et al., 2007 ). In addition, a substantial co-morbidity of AUD with psychiatric disorders has been documented: A high prevalence of co-morbid psychiatric disorders in individuals with AUD has been demonstrated in a number of large epidemiological studies (Regier et al, 1990, Penick et al, 1994, Tomasson and Vaglum, 1995, Kessler et al, 1997, Farrell et al, 2001, Kringlen et al, 2001, Grant et al, 2004a, and Hasin et al, 2007), and it has been shown that AUD is more prevalent among individuals with psychiatric disorders than in the general population (Kessler et al, 1996, Dixon, 1999, Spak et al, 2000, and Hasin et al, 2005). Finally, it has recently been found that AUD is registered before the co-morbid psychiatric disorder more often than the reverse temporal order ( Flensborg-Madsen et al., 2009 ). It is therefore reasonable to assume that alcohol is an important risk factor for the development of psychiatric disorders, and this hypothesis will be investigated in the present study, using a Danish longitudinal cohort study with linkage to Danish hospital registers. The aim of the present study was to investigate in a large population sample the prospective association between self-reported amount of alcohol intake and the later risk of being registered at a hospital with mood disorders, psychotic disorders, anxiety disorders, personality disorders, drug abuse and psychiatric disorders in general. The results will be stratified according to sex in order to investigate possible sex differences.
2.1. Study population
Data from the Copenhagen City Heart Study (CCHS) were used. CCHS is an ongoing series of studies conducted in the Danish population and initiated in 1976, when a random sample of men and women above 20 years of age and living in the Copenhagen area was invited to participate. The sample was randomly drawn from the Central Population Register, by use of the unique personal identification number, and invited by letter to answer self-administered questionnaires in the years 1976–1978. The number of participants was 14,223, with a response rate of 74%. This examination was followed by three follow-up examinations in the years 1981–1983 (CCHS II) (number of participants 12,698; response rate 70%), 1991–1993 (CCHS III) (number of participants 10,135; response rate 61%) and 2001–2003 (CCHS IV) (number of participants 6,238; response rate 50%). Data from the last examination, CCHS IV, were not used in these present analyses since the register follow-up only included data until the end of 2002. All follow-up examinations were supplemented with younger participants in order to keep the population large and representative. Detailed descriptions of the study have been published elsewhere (Appleyard et al, 1989, Schnohr et al, 2001, and Thygesen, 2008). A total of 18,146 individuals answered questionnaires on their alcohol intake and other lifestyle factors in three waves of the Copenhagen City Heart Study (CCHS I–III).
2.2. Assessment of alcohol consumption
Information on amount and frequency, and type of alcohol intake was obtained from CCHS I–III where participants were asked in multiple-choice format to describe their alcohol habits. In CCHS I, however, the weekly alcohol intake had to be calculated: As in CCHS II and III, participants in CCHS I were asked whether they “hardly ever/never,” “monthly,” “weekly,” or “daily” drank alcohol, but only if this intake was daily, was the average daily intake recorded. Thus, an absolute amount of consumed alcohol was obtainable only for persons stating a daily alcohol intake. Therefore the weekly intake in CCHS I was calculated by means of a series of regression models estimated from CCHS II. These were previously constructed by Becker et al. (1995) and include the explanatory variables age, sex, alcohol intake patterns and weekly alcohol intake. In all three waves, CCHS I–III, the average weekly intake of beer, wine and spirits was summed to the total alcohol intake (with one bottle of beer being approximately equivalent to the alcohol contents of one glass of wine or one glass of spirits, assuming each drink contains 12 g of alcohol).
Results are illustrated based on two different categorizations of alcohol: First, we divided individuals into five alcohol-drinking groups ( Fig. 2 a and b) using non-drinking individuals as the reference group. Then, we divided the study sample into those drinking below and those drinking above the sensible drinking guidelines and using the former category as the reference group ( Table 1 a and b).
|Number of drinks per week||Risk of mood disorders||Risk of psychotic disorders||Risk of anxiety disorders||Risk of personality disorders||Risk of drug abuse||Risk of any psychiatric disorder (other than AUD)|
|> 14||1.18 (0.83–1.68)||1.30 (0.72–2.32)||2.00 (1.31–3.04)||1.22 (0.73–2.04)||1.02 (0.43–2.38)||1.27 (0.98–1.66)|
|> 21||0.98 (0.68–1.41)||0.79 (0.45–1.40)||0.79 (0.42–1.50)||0.84 (0.48–1.47)||1.56 (0.90–2.69)||1.16 (0.91–1.47)|
2.3. Assessment of psychiatric disorders by linkage to national registers
All persons invited to CHHS I–III were followed by linkage with Danish registers using the unique personal identification number. The Danish Hospital Discharge Register ( Jurgensen et al., 1986 ) contains information on dates of hospital admissions and discharge diagnoses from Danish hospitals since 1976; the Danish Psychiatric Central Register ( Munk-Jorgensen and Mortensen, 1997 ) contains information on dates of hospital admissions and discharge diagnoses from Danish psychiatric hospitals since 1969; and the Danish Causes of Death Register ( Juel and Helweg-Larsen, 1999 ) contains information on causes of death of all Danish residents who died in Denmark since 1943. Diagnoses in the registers are classified according to the World Health Organization's International Classification of Diseases (ICD) using the eighth revision until 1994, and the 10th revision from 1994 and onwards.
Psychiatric disorders were in this study divided into the following categorizations: mood disorders, psychotic disorders, anxiety disorders, personality disorders, drug abuse, and all psychiatric disorders in general (except for individuals with only AUD). Individuals that were registered with the outcome disorder before their entry into the study were eliminated from the analyses. Many individuals had several diagnoses and a non-hierarchical approach was taken, meaning, that all individuals with a given diagnosis were included in the analysis of this specific outcome disorder. The following diagnostic categories were used:
- Mood disorders: ICD-8 (296, 300.4, 298.0), ICD-10 (F30-34, 38, 39)
- Psychotic disorders: ICD-8 (295, 297, 298.1-9, 299), ICD-10 (F20-29)
- Anxiety disorders: ICD-8 (300.0, 300.2, 300.3), ICD-10 (F40-43)
- Personality disorders: ICD-8 (301), ICD-10 (F60)
- Drug abuse: ICD-8 (304), ICD-10 (F11-19 – for only harmful use and dependence)
- Any psychiatric disorder: ICD-8 (28, 30, 31), ICD-10 (F1, F2, F3, F4, F5, F6, F7, F8, F9), minus AUD diagnoses
2.4. Assessment of possible confounding factors
A number of covariates were considered putative confounders in the association between alcohol intake and psychiatric disorders. The following were available in all three data collection follow-ups: sex, smoking (current smoker, previous smoker, and never smoker), cohabitation status (living alone, living with someone), and educational level (less than 8 years, 8–12 years, and more than 12 years). All results were adjusted for these factors.
2.5. Statistical analysis
The analyses used to estimate the risks of psychiatric disorders were Cox proportional hazard regression ( Collett, 2008 ). By including age as the time variable the estimates were adjusted for confounding by age. Subjects were followed from their date of entry, when they answered their first questionnaire between 1976 and 1993, to the date of the first registration of the psychiatric outcome disorder, death, disappearance, emigration, or until the end of follow-up (January 2002), whichever occurred first. The assumption of proportional hazards was tested for the main exposures by adding a time-dependent covariate (log t) to the regression model and testing the significance of this interaction with significance defined asp < 0.05. No violations were detected.
In contrast to time-fixed covariates, both the alcohol intake and the possible confounding factors from CCHS were time-dependent variables as they were measured repeatedly over time in 1976–1978, 1981–1983, and 1991–1993, with the number of observations and the time between the observations varying between subjects. The presented analyses were based on updated measures of alcohol consumption and confounders. In these analyses we prospectively assessed the risk of psychiatric disorders in between examination increments based on determinations of covariates derived from the preceding questionnaire. Technically, this means that several observations were analyzed for each individual who was characterized anew in each of the consecutive examinations and that information from all observation intervals was pooled as if the information recorded at each interval were a new observation. In case of missing data the last observation was carried forward. All analyses were performed using SAS software package SAS 9.1.
Fig. 1 shows the distribution of the amount of alcohol intake in CCHS I, illustrating that 13.8% of the study population drank above 21 drinks of alcohol per week. The study population was followed for up to 26 years in Danish registers in order to capture diagnoses of psychiatric disorders. Among the 18,146 individuals completing at least one of the three questionnaires in CCHS I–III, 965 (5.3%) individuals were registered with mood disorders, 382 (2.11%) with psychotic disorders, 333 (1.84%) with anxiety disorders, 602 (3.32%) with personality disorders, 295 (1.63%) with drug abuse, and 2092 (11.53%) were registered with some kind of psychiatric disorder other than AUD.
The patterns of risks of psychiatric disorders according to alcohol intake were different for men and women. For women, the overall pattern showed that large amounts of alcohol increased the risks of psychiatric disorders up to 2 times that of non-drinking women, mainly for anxiety disorders and psychiatric disorders in general ( Fig. 2 a and Table 1 a). Hence, the risk of anxiety disorders for women drinking 15–21 drinks per week was 1.92 (95% confidence interval (CI): 1.10–3.33) compared to women who did not drink alcohol ( Fig. 2 a) while the risk of anxiety disorders for women drinking above the sensible drinking limit of 14 drinks per week was 2.00 (95% CI: 1.31–3.04) compared to women drinking below the sensible drinking limit ( Table 1 a). The risk of any psychiatric disorder (except for AUD) for women drinking more than 21 drinks per week was 1.56 (95% CI: 1.06–2.31) compared to non-drinking women.
For men, there was no significantly increased risk of any psychiatric disorder with intakes above the sensible drinking limits ( Table 1 b). Although the estimates are not significant, there seemed to be a pattern of a protective effect of drinking above the recommendations ( Table 1 b). Moreover, the graphs in Fig. 2 a show a pattern of a protective effect of drinking some alcohol every week with the risk functions being slightly U-shaped. The risk of personality disorders was 0.50 (95% CI: 0.24–1.04) for men drinking 1–7 drinks per week, and 0.47 (95% CI: 0.22–1.00) for men drinking 8–14 drinks per week, compared to non-drinking men. The risk of psychiatric disorders in general was 0.68 (95 CI: 0.50–0.94) for men drinking 1–7 drinks per week and 0.68 (95% CI: 0.49–0.94) for men drinking 8–14 drinks per week, compared to non-drinking men.
Additional analyses were conducted to evaluate whether the risk curve for any psychiatric disorder would still be observed in men if drug abuse was not included in this category (data not shown). These results showed no substantial changes in the results.
These findings based on self-reported alcohol consumption and follow-up in Danish national hospital registers indicated that the association between alcohol intake and later risk of psychiatric disorders was different for men and women. For women, only a high weekly intake of alcohol showed a tendency towards an increased risk of psychiatric disorders, mainly anxiety disorders and psychiatric disorders in general, though the risks did not exceed more than 2.00. For men, the risk functions were slightly U-shaped and alcohol consumption was associated with an apparent protective effect against later development of psychiatric disorders.
4.1. Methodological issues
The advantages of this study are the prospective design, the large study population sample, a long follow-up time, register information on all psychiatric diagnoses, and several updated measures of alcohol intake and lifestyle covariates. Individuals having the outcome disorder before entrance into the study were eliminated from the analyses. Obtaining data on alcohol intake prospectively in several examinations meant that data on alcohol intake could be updated with each person being characterized anew in each of the following examinations, and thereby we had a unique opportunity to investigate the risk of admission to a hospital with a psychiatric diagnosis according to alcohol intake in the previous period. Had the follow-up time been longer, such as 30–40 years, the prevalence of hospitalization with organic disorders, such as alcoholic dementia caused by alcohol, would possibly be higher. Such disorders are, however, not the focus of this paper, and consequently we consider the follow-up time to be sufficient for the main diagnostic categories in the present study.
The advantage of assessing psychiatric disorders from registers is the ease by which the study population can be followed continuously for various endpoints. However, register data can also induce several biases, especially misclassification if for example individuals fulfilling criteria for a psychiatric disorder were not diagnosed at a Danish hospital, or if individuals not fulfilling criteria for a psychiatric disorder were diagnosed as such. Although all Danish residents have equal access to hospitals and all treatments are free of charge, misclassification of psychiatric disorders is still plausible. Compared with other psychiatric disorders, it has been shown that especially alcohol abuse and dependence are poor predictors of contacts with care providers ( Bijl and Ravelli, 2000 ). Hence, consuming large amounts of alcohol may itself delay the access to hospitalization of possible co-morbid psychiatric diseases, which in this study would mean that the risk of psychiatric disorders among the heaviest drinkers is underestimated. A previous study using Danish registers did however show that the risk of being registered with a psychiatric disorder in individuals already registered with AUD was greater than the risk of developing AUD in individuals who were already registered with another psychiatric disorder, especially among individuals with anxiety disorders, personality disorders, and drug abuse ( Flensborg-Madsen et al., 2009 ).
It has been discussed whether alcohol consumption may result in longer duration of psychiatric disorders ( Haynes et al., 2008 ). This may create an artificially strong association with some psychiatric disorders, but in the present study the most remarkable finding may be the lack of strong associations.
Patients may be affected by psychiatric disorders for longer or shorter periods before they are admitted, so in addition to possible differences in diagnostic practice, register-based research in psychiatric disorders is also subject to the potential noise and bias that this period may inflict. Hence, the time of onset of each psychiatric disorder is based on the time when the individual appeared in the registry, although in some cases it is likely that the disorder developed months or years before the individual entered treatment. The use of registers means than the study relies on clinicians at the somatic and psychiatric hospitals for diagnosis. The conclusions of this study may therefore not be generalized to all psychiatric symptoms and psychiatric disorders but may be used to describe the risk of being admitted to a hospital resulting in a psychiatric diagnosis.
4.2. Previous studies
The results from this study are not easily compared with those from other studies since the majority of those have focused only on heavy and obviously harmful alcohol consumption such as alcohol dependence or AUD. Thereby they do not investigate the potential effects of low or moderate consumptions of alcohol upon the risk of developing psychiatric disorders.
Among the few studies using self-report measures of alcohol consumption, mainly the association with depression has been investigated. Using symptom scales, a positive association between alcohol consumption and depression has been found in several studies (Hartka et al, 1991, Dixit and Crum, 2000, Rodgers et al, 2000, and Alati et al, 2005), supporting the results we found for women but not for men. In other studies it was found that this association was dependent on the measure of alcohol consumption (volume, frequency, binge drinking, etc.) (Schutte et al, 1995, Patten and Charney, 1998, Graham and Schmidt, 1999, and Graham et al, 2007). In one study, a U-shaped relationship between alcohol consumption and depression was demonstrated with abstainers being at greater risk of depressive symptoms than those with moderate alcohol consumption ( Lipton, 1994 ). This supports our results showing a higher risk of both depression and other psychiatric disorders among abstaining men compared to men drinking small or moderate amounts of alcohol. With respect to anxiety disorders, studies have yielded inconsistent support for the association with alcohol use. Some studies support our findings of a positive association among women (Rodgers et al, 2000, Stewart et al, 2001, and Koven et al, 2005); for example, a Danish study concluded that among women, moderate drinking was associated with anxiety and dysthymia symptom scales ( Mortensen et al., 2006 ). Other studies have been unable to detect an association (Novak et al, 2003 and Zack et al, 2006). The vast majority of studies using self-reported measures of alcohol were, however, cross-sectional, thereby making it difficult to draw conclusions regarding causality.
Among studies using alcohol disorders instead of alcohol intake to describe the association with other psychiatric disorders, the Epidemiologic Catchment Area Study found that among those with an alcohol disorder, 37% had a co-morbid mental disorder ( Regier et al., 1990 ). Co-morbid prevalences have been observed to be high for depression (Miller et al, 1996, Schuckit et al, 1997, and Gilman and Abraham, 2001), schizophrenia or schizophreniform disorder ( Regier et al., 1990 ), anxiety disorders ( Grant et al., 2004a ), personality disorders ( Grant et al., 2004b ) and drug abuse (Regier et al, 1990 and Hasin et al, 2007). Hence, the psychiatric co-morbidity of AUD is well established.
4.3. Alcohol and psychiatric disorders—explanations of the results
The results from the present study showed that among women, drinking above the sensible drinking limits increased the risk of psychiatric disorders while the risk function for men, conversely, was slightly U-shaped, showing an apparent protective effect of drinking alcohol. The increased risks among women may be consequences of alcohol consumption such as depressogenic effects of alcohol (Hamalainen et al, 2001 and Sher, 2003) or psychosocial consequences of problem drinking. It is also possible that women with psychiatric symptoms use alcohol as self-medication. One study showed that self-medication with alcohol was a common behavior in individuals with anxiety disorders and that these individuals were at increased risk of mood and substance use disorders ( Bolton et al., 2006 ).
The apparent protective effect of alcohol among men suggests that alcohol consumption among men may be a sign of mental and social well-being and normal functioning. A previous Danish study showed that compared to all other groups of drinkers, non-drinkers were more likely to be women, have a short education, have a low income, do little physical activity, to live alone, and to be currently unmarried ( Flensborg-Madsen et al., 2007 ). Another Danish study found that abstaining was associated with low social status family background, low education and low intelligence, and that compared to light drinkers, a more “carefree” life orientation characterized male moderate drinkers ( Mortensen et al., 2006 ). Hence, in men non-drinking might be an indicator of suboptimal mental and social functioning that may be associated with a higher risk of psychiatric disorders.
We know from a previous study that the risk of AUD increases rapidly with the weekly intake of alcohol (especially among women) ( Flensborg-Madsen et al., 2007 ), and it cannot be excluded that a diagnosis of AUD could mask the diagnosis of other psychiatric disorders. Fig. 2 a shows that, among men, alcohol consumption of 15–21 drinks per week substantially reduces risk of drug abuse. This may reflect the fact that alcohol in some people replaces other drugs. However, intake of more than 21 drinks per week increases the risk of drug abuse, and it is possible that heavy alcohol use is associated with a general disposition to substance abuse ( Mayer and Hollt, 2005 ). The additional analyses evaluating whether the slightly U-shaped risk curve for any psychiatric disorder would still be observed in men if drug abuse was not included in this category showed no substantial changes in the results. Thus, the U-shaped curve cannot be explained by an association between alcohol consumption and drug abuse.
The Danish sensible drinking limits are primarily set up based on the risk of alcohol-related physical diseases and mortality. While 14 and 21 drinks per week may be risky in relation to the physical influences of alcohol on the body, it is not necessarily a high intake when social and psychological effects are considered. The limits correspond to two to three drinks per day (if the intake is spread out over the week), and according to the results of the present study, this intake is not sufficient to increase the risk of psychiatric disorders.
Few longitudinal population studies have been conducted to evaluate the associations between alcohol intake and psychiatric disorders. The main conclusion from this study is that in this study population, the majority of individuals consuming more than recommended amounts of alcohol did not develop a psychiatric disorder. Women drinking above the sensible drinking limits showed an increase in risk of psychiatric disorders. The risk function for men, conversely, was slightly U-shaped, showing an apparent protective effect of drinking alcohol compared to not drinking alcohol.
Although this study is based on a large population sample, psychiatric outcome diagnoses were obtained from hospital records and consequently, the result may not be applicable to mental disorders not leading to hospitalization. Nevertheless, a very large percentage (11.53%) of this population sample was registered in a Danish hospital with a psychiatric diagnosis other than AUD, underlining the importance of the results. If it is a fact that alcohol is not generally a risk factor for psychiatric disorders, the etiology of AUD and other psychiatric disorders is obviously not very similar, and this may be of interest to general practitioners as well as to researchers who investigate psychiatric co-morbidity. Thus, an important issue is whether future prospective population studies of self-reported alcohol intake and later risk of psychiatric symptoms (self-reported or as diagnosed by a psychiatrist) would find results similar to the present study.
This study was supported by a research grant from the Lundbeck Foundation grant no. 9/05, a grant from the Danish Medical Research Council grant no. 271-05-0149, and a grant from the IMK Almene Fond.
- Alati et al., 2005 R. Alati, D.A. Lawlor, J.M. Najman, G.M. Williams, W. Bor, M. O'Callaghan. Is there really a ‘J-shaped’ curve in the association between alcohol consumption and symptoms of depression and anxiety? Findings from the Mater-University Study of Pregnancy and its outcomes. Addiction. 2005;100:643-651
- Appleyard et al., 1989 M. Appleyard, A.T. Hansen, P. Schnohr, G.N. Jensen. The Copenhagen City Heart Study. Osterbroundersogelsen. A book of tables with data from the first examination (1976–78) and a five year follow-up (1981–83). The Copenhagen City Heart Study Group. Scandinavian Journal of Social Medicine Supplement. 1989;41:1-160
- Becker et al., 1995 U. Becker, A. Deis, T.I.A. Sørensen, M. Grønbæk, C.F. Müller, P. Schnohr, K. Borch-Johnsen, G. Jensen. Alcohol intake in a population study: assessment and characterization. ALCOLOGIA. 1995;7:35-42
- Bijl and Ravelli, 2000 R.V. Bijl, A. Ravelli. Psychiatric morbidity, service use, and need for care in the general population: results of The Netherlands Mental Health Survey and Incidence Study. American Journal of Public Health. 2000;90:602-607
- Bolton et al., 2006 J. Bolton, B. Cox, I. Clara, J. Sareen. Use of alcohol and drugs to self-medicate anxiety disorders in a nationally representative sample. The Journal of Nervous and Mental Disease. 2006;194:818-825
- Collett, 2008 Collett D. Modelling survival data in medical research Second edn (Chapman & Hall/CRC Press LLC, United States of America, 2008)
- Dixit and Crum, 2000 A.R. Dixit, R.M. Crum. Prospective study of depression and the risk of heavy alcohol use in women. The American Journal of Psychiatry. 2000;157:751-758
- Dixon, 1999 Dixon L. Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophrenia Research. 1999;35:93-100 (Suppl.)
- Farrell et al., 2001 M. Farrell, S. Howes, P. Bebbington, T. Brugha, R. Jenkins, G. Lewis, J. Marsden, C. Taylor, H. Meltzer. Nicotine, alcohol and drug dependence and psychiatric comorbidity. Results of a national household survey. The British Journal of Psychiatry. 2001;179:432-437
- Flensborg-Madsen et al., 2007 T. Flensborg-Madsen, J. Knop, E.L. Mortensen, U. Becker, M. Gronbaek. Amount of alcohol consumption and risk of developing alcoholism in men and women. Alcohol and Alcoholism. 2007;42:442-447
- Flensborg-Madsen et al., 2009 T. Flensborg-Madsen, E.L. Mortensen, J. Knop, U. Becker, L. Sher, M. Gronbaek. Comorbidity and temporal ordering of alcohol use disorders and other psychiatric disorders: results from a Danish register-based study. Comprehensive Psychiatry. 2009;50:307-314
- Gilman and Abraham, 2001 S.E. Gilman, H.D. Abraham. A longitudinal study of the order of onset of alcohol dependence and major depression. Drug and Alcohol Dependence. 2001;63:277-286
- Graham et al., 2007 K. Graham, A. Massak, A. Demers, J. Rehm. Does the association between alcohol consumption and depression depend on how they are measured?. Alcoholism, Clinical and Experimental Research. 2007;31:78-88
- Graham and Schmidt, 1999 K. Graham, G. Schmidt. Alcohol use and psychosocial well-being among older adults. Journal of Studies on Alcohol. 1999;60:345-351
- Grant et al., 2004a B.F. Grant, F.S. Stinson, D.A. Dawson, S.P. Chou, M.C. Dufour, W. Compton, R.P. Pickering, K. Kaplan. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry. 2004;61:807-816
- Grant et al., 2004b B.F. Grant, F.S. Stinson, D.A. Dawson, S.P. Chou, W.J. Ruan, R.P. Pickering. Co-occurrence of 12-month alcohol and drug use disorders and personality disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry. 2004;61:361-368
- Hamalainen et al., 2001 J. Hamalainen, J. Kaprio, E. Isometsa, M. Heikkinen, K. Poikolainen, S. Lindeman, H. Aro. Cigarette smoking, alcohol intoxication and major depressive episode in a representative population sample. Journal of Epidemiology and Community Health. 2001;55:573-576
- Hartka et al., 1991 E. Hartka, B. Johnstone, E.V. Leino, M. Motoyoshi, M.T. Temple, K.M. Fillmore. A meta-analysis of depressive symptomatology and alcohol consumption over time. British Journal of Addiction. 1991;86:1283-1298
- Hasin et al., 2005 D.S. Hasin, R.D. Goodwin, F.S. Stinson, B.F. Grant. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Archives of General Psychiatry. 2005;62:1097-1106
- Hasin et al., 2007 D.S. Hasin, F.S. Stinson, E. Ogburn, B.F. Grant. 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. Archives of General Psychiatry. 2007;64:830-842
- Haynes et al., 2008 J.C. Haynes, M. Farrell, N. Singleton, H. Meltzer, R. Araya, G. Lewis, N.J. Wiles. Alcohol consumption as a risk factor for non-recovery from common mental disorder: results from the longitudinal follow-up of the National Psychiatric Morbidity Survey. Psychological Medicine. 2008;38:451-455
- Juel and Helweg-Larsen, 1999 K. Juel, K. Helweg-Larsen. The Danish registers of causes of death. Danish Medical Bulletin. 1999;46:354-357
- Jurgensen et al., 1986 H.J. Jurgensen, C. Frolund, J. Gustafsen, H. Mosbech, B. Guldhammer, J. Mosbech. Registration of diagnoses in the Danish National Registry of Patients. Methods of Information in Medicine. 1986;25:158-164
- Kessler et al., 1997 R.C. Kessler, R.M. Crum, L.A. Warner, C.B. Nelson, J. Schulenberg, J.C. Anthony. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Archives of General Psychiatry. 1997;54:313-321
- Kessler et al., 1996 R.C. Kessler, C.B. Nelson, K.A. McGonagle, J. Liu, M. Swartz, D.G. Blazer. Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey. The British Journal of Psychiatry. Supplement. 1996;30:17-30
- Koven et al., 2005 N.S. Koven, W. Heller, G.A. Miller. The unique relationship between fear of cognitive dyscontrol and self-reports of problematic drinking. Addictive Behaviors. 2005;30:489-499
- Kringlen et al., 2001 E. Kringlen, S. Torgersen, V. Cramer. A Norwegian psychiatric epidemiological study. The American Journal of Psychiatry. 2001;158:1091-1098
- Lipton, 1994 R.I. Lipton. The effect of moderate alcohol use on the relationship between stress and depression. American Journal of Public Health. 1994;84:1913-1917
- Mayer and Hollt, 2005 P. Mayer, V. Hollt. Genetic disposition to addictive disorders—current knowledge and future perspectives. Current Opinion in Pharmacology. 2005;5:4-8
- Miller et al., 1996 N.S. Miller, D. Klamen, N.G. Hoffmann, J.A. Flaherty. Prevalence of depression and alcohol and other drug dependence in addictions treatment populations. Journal of Psychoactive Drugs. 1996;28:111-124
- Mørch et al., 2005 L.S. Mørch, U. Becker, J. Olsen, A.M. Tjonneland, M.N. Grønbæk. Should the sensible drinking limits for adults be changed?. Ugeskrift for Laeger. 2005;167:3777-3779
- Mortensen et al., 2006 E.L. Mortensen, H.H. Jensen, S.A. Sanders, J.M. Reinisch. Associations between volume of alcohol consumption and social status, intelligence, and personality in a sample of young adult Danes. Scandinavian Journal of Psychology. 2006;47:387-398
- Munk-Jorgensen and Mortensen, 1997 P. Munk-Jorgensen, P.B. Mortensen. The Danish Psychiatric Central Register. Danish Medical Bulletin. 1997;44:82-84
- Novak et al., 2003 A. Novak, E.S. Burgess, M. Clark, M.J. Zvolensky, R.A. Brown. Anxiety sensitivity, self-reported motives for alcohol and nicotine use, and level of consumption. Journal of Anxiety Disorders. 2003;17:165-180
- Patten and Charney, 1998 S.B. Patten, D.A. Charney. Alcohol consumption and major depression in the Canadian population. Canadian Journal of Psychiatry-Revue Canadienne De Psychiatrie. 1998;43:502-506
- Penick et al., 1994 E.C. Penick, B.J. Powell, E.J. Nickel, S.F. Bingham, K.R. Riesenmy, M.R. Read, J. Campbell. Co-morbidity of lifetime psychiatric disorder among male alcoholic patients. Alcoholism, Clinical and Experimental Research. 1994;18:1289-1293
- Regier et al., 1990 D.A. Regier, M.E. Farmer, D.S. Rae, B.Z. Locke, S.J. Keith, L.L. Judd, F.K. Goodwin. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. Journal of the American Medical Association. 1990;264:2511-2518
- Rodgers et al., 2000 B. Rodgers, A.E. Korten, A.F. Jorm, P.A. Jacomb, H. Christensen, A.S. Henderson. Non-linear relationships in associations of depression and anxiety with alcohol use. Psychological Medicine. 2000;30:421-432
- Schnohr et al., 2001 Schnohr P., Jensen G., Lange P., Scharling H., Appleyard M. The Copenhagen City Heart Study - Østerbroundersøgelsen. Tables with data from the third examination 1991–94. European Heart Journal.Supplement. 2001;:H1-H83
- Schuckit et al., 1997 M.A. Schuckit, J.E. Tipp, K.K. Bucholz, J.I. Nurnberger Jr., V.M. Hesselbrock, R.R. Crowe, J. Kramer. The life-time rates of three major mood disorders and four major anxiety disorders in alcoholics and controls. Addiction. 1997;92:1289-1304
- Schutte et al., 1995 K.K. Schutte, R.H. Moos, P.L. Brennan. Depression and drinking behavior among women and men: a three-wave longitudinal study of older adults. Journal of Consulting and Clinical Psychology. 1995;63:810-822
- Sher, 2003 L. Sher. Effects of heavy alcohol consumption on the cardiovascular system may be mediated in part by the influence of alcohol-induced depression on the immune system. Medical Hypotheses. 2003;60:702-706
- Spak et al., 2000 L. Spak, F. Spak, P. Allebeck. Alcoholism and depression in a Swedish female population: co-morbidity and risk factors. Acta Psychiatrica Scandinavica. 2000;102:44-51
- Stewart et al., 2001 S.H. Stewart, M.J. Zvolensky, G.H. Eifert. Negative-reinforcement drinking motives mediate the relation between anxiety sensitivity and increased drinking behavior. Personality and Individual Differences. 2001;31:157-171
- Thygesen, 2008 Thygesen L.C. Alcohol intake and risk of cancer. Prospective studies with repeated measurements of exposure (Centre for Alcohol Research. National Institute of Public Health, University of Southern Denmark, 2008)
- Tomasson and Vaglum, 1995 K. Tomasson, P. Vaglum. A nationwide representative sample of treatment-seeking alcoholics: a study of psychiatric comorbidity. Acta Psychiatrica Scandinavica. 1995;92:378-385
- Webster-Harrison et al., 2001 P.J. Webster-Harrison, A.G. Barton, S.M. Barton, S.D. Anderson. General practitioners' and practice nurses' knowledge of how much patients should and do drink. The British Journal of General Practice. 2001;51:218-220
- Zack et al., 2006 M. Zack, C.X. Poulos, F. Fragopoulos, T.M. Woodford, C.M. MacLeod. Negative affect words prime beer consumption in young drinkers. Addictive Behaviors. 2006;31:169-173
a Research Programme on Lifestyle and Health, National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5, 1399 København K, Denmark
b Alcohol Unit, Hvidovre Hospital, University of Copenhagen, Kettegårds Allé 30, 2650 Hvidovre, Denmark
c National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5, 1399 København K, Denmark
d Institute of Preventive Medicine, Copenhagen Capital Region, Copenhagen University Hospitals, Øster Søgade 18, 1, DK - 1357 Copenhagen K, Denmark
e Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 42, New York, NY 10032, USA
f Department of Environmental Health, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, opg.Z 1.sal, 1353 København K, Denmark
© 2010 Elsevier Ltd, All rights reserved.
This study found that women drinking above the sensible drinking limits (in Denmark: 14 drinks per week for women; 21 for men) showed an increase in risk of psychiatric disorders, especially anxiety disorders (a risk of 2.00 compared to women drinking below this limit). The risk function for men was slightly U-shaped, showing an apparent protective effect of drinking alcohol compared to not drinking alcohol. The psychiatric outcome diagnoses used in this study were obtained from hospital records and consequently, the result may not be applicable to mental disorders not leading to hospitalization. The authors speculate that, had the follow-up time been longer, such as 30–40 years, the prevalence of hospitalization with organic disorders, such as alcoholic dementia caused by alcohol, would possibly be higher.
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