Longitudinal association between different levels of alcohol consumption and a new onset of depression and generalized anxiety disorder: Results from an international study in primary care
Introduction
Traditionally, psychiatric research considers alcohol as a harmful substance focusing mainly on the extreme of excessive alcohol consumption. From a public health perspective, however, evaluating the effects of abstinence and moderate use of alcohol are equally important because they are much more common compared to alcohol dependence or abuse, while alcohol is incorporated in everyday nutrition of several cultures e.g. Mediterranean and South-American cultures (Room and Mäkelä, 2000).
Several cross-sectional (Bellos et al., 2013, Caldwell et al., 2002, Kirchner et al., 2007, O’Donnell et al., 2006, Power et al., 1998, Skogen et al., 2009) and longitudinal studies (Bell and Britton, 2015, Bell et al., 2014; Cougle et al., 2015, Gea et al., 2013, Gea et al., 2012, Tait et al., 2012) that have examined the full range of consumption, from total abstinence to excessive use, have pointed to a possible non-linear association between alcohol use and the common mental disorders. It has been suggested that moderate levels of alcohol consumption are associated with a lower risk of mental health problems compared to total abstinence or heavy use, reflecting the analogous association of reduced mortality with moderate alcohol use (Ronksley et al., 2011). These findings are not universally accepted and have been questioned as being the result of unmeasured confounding factors or reverse causality (Bell and Britton, 2015, Holmes et al., 2014; Paljärvi et al., 2009; Paschall et al., 2005, Sareen et al., 2004). Regarding the latter, the “sick-quitter” effect (Fillmore et al., 2007) could explain the increased prevalence of mental disorders in individuals abstaining from alcohol compared to moderate users (Bell et al., 2014), while the self-medication hypothesis (Bolton et al., 2009) may explain the association between heavy alcohol use and depression.
The above discussion is of particular interest for patients presenting in Primary Care where alcohol related problems and depression are common and often co-occur with physical health problems. Previous longitudinal studies on the association between the different levels of alcohol consumption and the common mental disorders cannot generalize their results in other cultures or clinical settings as they recruited community samples from well developed countries (Gea et al., 2013, Haynes et al., 2005; Paljärvi et al., 2009; Tait et al., 2012) and assessed depression/anxiety using self-reported diagnoses (Bell and Britton, 2015; Gea et al., 2013) or generic case-finding instruments (Paljärvi et al., 2009; Tait et al., 2012) that may lack clinical validity. The available primary care studies on the association between different levels of alcohol consumption and depression or anxiety are cross sectional (Bellos et al., 2013, Kirchner et al., 2007) and cannot exclude the possibility of reverse causality.
In a previous work of our research team (Bellos et al., 2013), using the cross-sectional baseline data from a WHO international study in primary health care, we found evidence for a non-linear association between the full range of alcohol use and depression or generalized anxiety disorder (GAD). Longitudinal data are also available from the same dataset in a subset of participants, who were followed-up for one year after the baseline assessment. Therefore, the aim of the current paper was to investigate the longitudinal association between different levels of alcohol consumption and a new-onset of depression or GAD in order to confirm whether the previously reported non-linear association is not the result of reverse causality.
Section snippets
General description of the data set
The WHO collaborative study of Psychological Problems in General Health Care (PPGHC) investigated the prevalence and associations of common mental disorders in 15 primary care centres from 14 countries worldwide (Ustun and Sartorius, 1995). The study consisted of a cross-sectional part and a one-year longitudinal extension. The cross-sectional part used a two-phase design. At the first phase, 25,916 consecutive primary care attenders aged 18–65 completed the 12-item General Health Questionnaire
Sample characteristics – alcohol consumption
The 3201 primary care patients who took part at the follow-up had a mean age at baseline of 40.5 years (range: 18–65), while 62% were female. Comorbidity with a chronic medical disease was reported by 58.3% of the participants. The other baseline characteristics of the participants who took part in the follow-up were similar to those presented in our previous cross-sectional paper (Bellos et al., 2013). A new episode of depression (among participants without depression at baseline, N=2372) was
Key findings
Our results support a non-linear association between alcohol consumption and a new onset of depression and generalized anxiety disorder. In particular, participants with moderate alcohol consumption at baseline had a lower risk for developing a new onset of depression or GAD at follow-up compared to participants who abstained from alcohol at baseline. In addition, we confirmed that excessive alcohol consumption increased the risk for a new onset of depression while the association of
Acknowledgements
The data reported in this article were collected as part of a World Health Organization's Psychological Problems in General Health Care project. Participating investigators include: O. Ozturk and M. Rezaki, Ankara, Turkey; C. Stefanis and V. Mavreas, Athens, Greece; S.M. Channabasavana and T.G. Sriram, Bangalore, India; H. Helmchen and M. Linden, Berlin, Germany; W. van der Brink and B. Tiemens, Groningen the Netherlands; M. Olatawura and O. Gureye, Ibadan, Nigeria; O. Benkert and W. Maier,
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