Patterns of alcohol use and psychiatric inpatient admissions

0740-5472/88$3.00 + .oO Copyright0 1988PergamonPressplc

Journal of Substance Abuse Treatment, Vol. 5, pp. 27-31, 1988

Primedin the USA. All rightsreserved.

ORIGINAL

CONTRIBUTION

Patterns of Alcohol Use and Psychiatric Inpatient Admissions JUDITH BLACKWELL,

PhD

Brock University JOHN BERESFORD,

MD

Emergency Services Division, Clarke Institute of Psychiatry SYLVIA LAMBERT,

BA

Addiction Research Foundation

Abstract - The role of alcohol problems in psychiatric inpatient hospital admissions is not fully reflected in diagnostic statistics. A model is presented to guide the design and aid the interpretation of epidemiological research into the relationships between alcohol use and psychiatric disorder. The difficulties encountered in evaluating the role of alcohol in hospitalizations are discussed. Our preliminary research suggests that not enough attention has been paid to self-imposed abstinence from alcohol as a precipitant of symptoms and a precursor to hospitalization.

ine the role of drinking patterns in admissions to treatment in an inpatient psychiatric setting.

THE PRESENCE OF any psychiatric disorder increases the odds of co-occurrence of almost any other disorder (Boyd et al., 1984). Patients with major psy-

chiatric disorders and conjoint substance use problems undoubtedly have been with us always, but only recently have they become the object of systematic research. Meyer and Hesselbrock (1984) have described the relationship between psychopathology and the substance use disorders as “a situation of extreme multivariate complexity.” Psychopathology may be a risk factor for substance use disorders or may develop as a consequence; the two conditions also may coexist in the absence of an aetiological relationship. In this paper, we have set aside the issue of diagnostic hierarchy and concern ourselves with the mechanisms by which alcohol can influence how people become psychiatric patients. Specifically, we will exam-

AN ALCOHOL-PSYCHOPATHOLOGY MODEL

As a basis for our discussion we have constructed a diagrammatic model of overlapping populations (Figure 1). Epidemiological research has not progressed to the point where the relative sizes of the model’s subpopulations can be estimated accurately. However, the model is presented for its heuristic value, to guide our understanding of the relationships between alcohol consumption and psychiatric disorder. The larger circle represents the alcohol users in society, comprising non-problem drinkers (A,) and the subpopulation of problem drinkers (A,). We have defined “problem drinkers” as those who meet the criteria for DSM-III diagnosis of alcohol abuse or alcohol dependence (American Psychiatric Association, 1980). Not all members of the A2 group will be clinically diagnosed, however, and only some of them will be involved in psychiatric inpatient treatment at any given time. The smaller circle represents psychiatric inpatients,

Requests fo; reprints should be sent to Judith Blackwell, Assistant Professor of Sociology, Brock University, St. Catharines, Ontario, L2S 3Al. This work was done with the support of the Addiction Research Foundation. Thanks are due to Joan Moreau and Lecia Hanycz for the preparation of the manuscript. The views expressed are those of the authors and do not necessarily reflect those of any institution.

27

J. Blackwell et al.

Non-Problem

Alcohol

Problem

Users

Drinkers

A,

= ALCOHOL USERS, who do not meet DSM-III criteria alcohol abuse/dependence. A2 = PROBLEM DRINKERS, who do meet DSM-III criteria alcohol abuse/dependence. P = PSYCHIATRIC PATIENTS, who do not drink alcohol. PA, = PSYCHIATRIC PATIENT ALCOHOL USERS, who do meet DSM-III criteria for alcohol abuse/dependence. PAP = PSYCHIATRIC PATIENT PROBLEM DRINKERS, who meet DSM-III criteria for alcohol abuse/dependence. FIGURE 1. The alcohol-psychopathology

for for

not do

model.

some of whom will be non-drinkers (P). The remaining psychiatric patients are drinkers (PA,) or diagnosed problem drinkers (PAZ). Some of the PA2 group will have a single Axis I alcohol-related psychiatric diagnosis; others will have schizophrenia, affective disorder or other Axis I diagnoses, but also meet the criteria for an alcohol-related diagnosis. The relative proportions of these two types of PA2 inpatients in any given psychiatric service will depend upon a number of factors, as discussed below. EPIDEMIOLOGICAL

ISSUES

Numerous studies have identified high rates of alcohol use and alcohol-related problems in psychiatric inpatient samples (Alterman, Erdlen, & McLellan, 1980; Fowler, Liskow, Tanna, & Van Valkenburg, 1977: McCourt, Williams, & Schneider, 1971; Moore, 1972; Pokorny, 1965). In order to evaluate these findings from an epidemiological standpoint, however, we must examine the conditions under which an AZ problem drinker may become a PA2 psychiatric patient. In some communities, alcohol-specific detoxification and treatment facilities are not readily available, and psychiatric services will receive a disproportionate number of inpatients who might have been treated

in a non-psychiatric setting elsewhere. In the United States, AZ veterans will use Veterans Administration psychiatric hospitals for treatment, whereas the nonveteran AZ group may be more likely to appeal to non-psychiatric treatment agencies. Private psychiatric hospitals receive some of the AZ problem drinkers who can afford to pay for treatment. Because the relative proportions of patients with a single alcoholrelated Axis I diagnosis and those with conjoint diagnoses will vary from one service to another, rates of alcohol problems identified in any one setting are of limited epidemiological usefulness. A solution to this problem can be found by specifying the proportion of identified PA2 patients who have only an alcohol-related diagnosis and then reporting the diagnostic distribution of those that remain. Other studies have simply excluded patients in primary alcohol treatment from the sampling frame (Davis, 1984; McLellan, Druley, & Carson, 1978; O’Farrell, Connors, & Upper, 1983; Ritzler, Strauss, Vandor, & Kokes, 1977). Even then high rates of alcohol problems are uncovered. Unfortunately, this methodology cannot be relied upon entirely, because within some populations there are PA2 patients masquerading as PA,, that is, patients who fail to report alcohol problems. For example, McLellan et al. (1978) interviewed a sample of Veterans Administration psychiatric patients, deliberately excluding those in treatment for alcohol and other drug problems. One quarter of the patients studied admitted to having an alcohol problem, and 15% said that it motivated their entry into treatment. They wanted help, but also wanted to avoid public exposure of their alcohol problems. The extent to which PA2 patients are hidden in the apparently PAi inpatient population will vary from one setting to another, depending on the attitudes of the patients and the diligence of diagnosticians with regard to uncovering alcohol problems (Atkinson, 1973; Moore, 1972). Because the true incidence of alcohol problems evidently is higher than diagnostic data would indicate, independent measures must be employed to identify the full extent of alcohol problems in psychiatric patients. Other research suggests yet another epidemiological problem: that among the non-institutionalized A2 problem drinkers are individuals who are deserving of treatment for major psychiatric disorders, but who do not gain PA2 status because their alcohol problems mask the psychopathology. Thus, Parker, Meiller, and Andrews (1960) observed that the families, friends, and physicians of individuals with multiple disorders considered the alcohol problem to be primary; as a result, treatment of the major mental illness was postponed. Morrison (1974) observed that patients with both bipolar affective disorder and alcohol dependence had a longer duration of illness before

Patterns of Akohol

Use

29

admission than non-alcoholic bipolar patients, and his data suggest that symptoms, particularly depression, had been masked by the alcohol problem. More recently, Hudson and Perkins (1984) reported on four cases of panic disorder where the diagnosis was delayed or obscured by alcohol dependence. In sum, alcohol problems are hidden in psychiatric patient populations and unidentified and untreated major mental illnesses are contained within the problem drinking population. Epidemiologists who set out to evaluate the concurrence between alcohol problems and the various psychiatric disorders must take account of these concealed cases. ALCOHOL PSYCHIATRIC

PROBLEMS AND HOSPITALIZATION

To what extent do alcohol problems contribute to psychiatric hospital admissions? One study of four acute psychiatric services in three counties discovered that, next to agitation, the most frequently reported presenting symptoms were alcohol related (Muller, Chafetz, & Blane, 1967). Less than one quarter of these cases received a primary diagnosis related to drinking. Trier and Levy (1969) found alcohol to be a “contributing” factor in 39% of “emergent” cases. The impact of alcohol on admissions can be expected to vary over time and from one setting to another, but by all indications it continues to be a clinically important factor. Studies have shown how excessive alcohol use increases the rate of hospitalization across the whole range of psychiatric disorders (Pokorny, 1965) and specifically in affective disorder patients (Morrison, 1974; Reich, Davies, & Himmelhoch, 1974). A patient of one of us provides an excellent example of how alcohol problems contribute to the “revolving door syndrome” in psychiatric patient populations. This was a schizophrenic who, upon receipt of his disability allowance, would stop taking his medications and start drinking. At the age of 30, he had been admitted 38 times in 10 years, usually in a state of acute intoxication. DRINKING AND HOSPITALIZATION: SOME OBSERVATIONS

This individual participated in an exploratory study in preparation for research on alcohol and other drug use among consecutive psychiatric crisis admissions. The service where his project was conducted admits patients with a wide range of psychiatric problems of varying degrees of chronicity and severity. The patients range from adolescents to senior citizens, and the sex ratio is balanced. Provincial health insurance permits access to the institution by patients from a broad spectrum of social classes.

As this was pilot work we did not attempt to randomly sample the patient population, but rather selected 28 patients to represent four diagnostic categories (schizophrenia, affective disorder, personality disorder, other), both sexes and a broad age range. Prior knowledge of the alcohol or other drug use patterns of potential respondents did not enter into the sample selection process. After explaining the research and obtaining informed consent, the respondents were interviewed and data were extracted from their medical records. The structured interview schedule addressed alcohol consumption as one of a broad range of licit and illicit drugs. Comparisons between chart data and the responses during the interviews revealed a satisfactory level of reliability. Although no generalizations can be made from a relatively small non-random sample, some of our findings with regard to the role of alcohol use in hospital admissions are provocative. The drinking status of the pilot respondents in the pre-admission period is presented in Table 1. We analyzed these cases both with reference to clinical record data on their presenting symptoms, and also on the basis of their interview responses concerning the relationship between alcohol use and their mental health. We concluded that between those whose admissions were clearly related to drinking (e.g. alcohol problems included among presenting symptoms or intoxicated at admission) and those that were clearly unrelated (e.g., abstemious respondents), there were cases where alcohol may have exerted varying degrees of influence. We attempted to apply a six-category ranking system developed by Atkinson (1973) to evaluate the relevance of alcohol in emergency episodes, but with many of our respondents there were difficulties in making the fine distinctions necessary. For example, one pilot respondent told us that his alcohol consumption had increased in the month before his admission, where he presented with complaints of depression, anxiety, and thoughts of suicide. When asked if drinking had anything to do with coming to the hospital, he said “it may have had some sort of influence.” The precipitants of admission recorded on his chart included an unrewarding job, death of a

TABLE 1 Alcohol status of pilot respondents at admission.

Attempted abstinence or control (pre-admission period) Drinking problem among presenting problems (intoxicated at admission: n = 2) Increased drinking in pre-admission period No evidence of role of alcohol in admission Abstemious (no alcohol use)

4 6 3 12 3

n=28

30

J. Blackwell et al.

family member and a recent break-up with his girlfriend. This patient was experiencing so many life problems that the significance of his alcohol consumption was difficult to quantify. We concluded that a new scaling technique is needed, one that encompasses both life events and self-reports of patients. Another important consideration is that some moderate drinkers increase their consumption in response to the problems which eventually lead to their hospitalization. Evidence points to attempted self-medication as the motivating factor behind this behaviour (Reich et al., 1974). Ritzler et al. (1977) called such patients “escape” drinkers, and they were reported to have the least pathology and best prognosis of all the drinking groups examined. The authors suggested that an increase in drinking before admission is an essentially healthy coping mechanism. If indeed this behaviour represents attempted self-medication, it remains a moot question whether alcohol contributes to, delays or has little influence on subsequent hospital admission. In evaluating the role of drinking in hospitalization, it is also necessary to keep in mind that some patients may exaggerate their alcohol problems to increase their chances of admission (Crowley, Chesluk, Dilt, & Hart, 1974). We interviewed a chronic schizophrenic who recently had established a commonlaw relationship with a man who drank heavily. Her consumption had increased accordingly and she defined her current crisis as an “alcohol problem.” At admission, she reported her maximum daily consumption of alcohol as her average daily use. ABSTINENCE AND HOSPITALIZATION: FURTHER OBSERVATIONS By comparing information on alcohol consumption patterns obtained in the post-admission interview to the chronology of pre-admission events recorded in the medical histories, we uncovered a sequence that we had not anticipated. In four respondents, the presenting symptoms emerged after attempted abstinence from alcohol; these cases made up almost 20% of the regular drinkers in the sample (i.e., those who normally drank more often than once a month). We believe that this is a phenomenon deserving further study. In one case, a manic episode began during a month of self-imposed abstinence, and was then followed by uncharacteristically heavy drinking in the preadmission period. A heavy drinker with a previous admission for affective disorder had been reducing his consumption for some time, finally achieving abstinence; during a period of two months he became increasingly depressed and was re-admitted to hospital. A third respondent presented with overwhelming anxiety; he was a former alcohol dependent who had

been “trying to ease off” and who had been abstinent for a week before admission. Finally, a borderline personality disorder patient had been prompted to stop drinking after joining a religious sect; three weeks later, he developed fantasies of genital mutilation and suicidal thoughts which increased in severity until his hospitalization. These individuals had been asked about their motivations for drinking in the post-admission interview. The manic bipolar patient said alcohol made him “cool and serene.” The depressed patient reported that alcohol increased his self-esteem and made “reality more pleasant.” The former alcohol dependent, later discharged with a diagnosis of generalized anxiety, told our interviewer that he drank for “freedom from anxiety.” The borderline patient said, “Alcohol works better than anything else for emotional upsets.” None of these individuals articulated a connection between attempted control over alcohol consumption and the onset of symptoms. However, the remarkable similarity between symptoms ameliorated by drinking and the presenting symptoms at admission strongly suggests that abstinence played a role in their hospitalization. SUMMARY AND CONCLUSIONS In this paper, we have developed a model to aid the interpretation of studies of alcohol use among psychiatric inpatients and to guide the design of future epidemiological research. We have also outlined the various ways in which drinking behaviour can be an influence in hospital admissions. Clearly, many psychiatric hospitalizations are prompted by or preceded by heavy alcohol consumption or drinking problems. It is a truism that drinking can both cause and exacerbate psychiatric disorders. However, more research is needed to develop sufficiently sensitive methodologies to discriminate the role of alcohol problems in hospital admissions in an epidemiologically meaningful way. This line of research must also take into account both the possibility that drinking for self-medication or for coping with a crisis may postpone or, indeed, pre-empt hospitalization in some cases. The most striking observation to emerge from our exploratory work is the potential importance of abstinence from alcohol. That heavy drinking is perceived as such a serious problem perhaps obscures the possible clinical significance of abstemiousness, particularly in former heavy drinkers. This may be the reason it has tended to be overlooked by clinicians and researchers alike. An exceptional study in this regard reported that of all the drinking groups observed, abstainers had the poorest prognosis (Ritzler et al., 1977). The investigators suggested that for some, abstention from alcohol reflected rigidity, poor

31

Patterns of Alcohol Use

coping skills, and social isolation. This, too, is an issue that calls for more research. We would agree that “. . . undetected substance abuse may complicate or completely confound diagnosis and treatment of primary psychiatric problems” (McLellan et al., 1978 p. 425). We would also suggest that undetected abstinence may present similar problems. REFERENCES Alterman, A., Erdlen, F., McLellan, A. (1980). Problem drinking in a psychiatric hospital: Alcoholic schizophrenics. In E. Gottheil, A.T. McLellan, & K.A. Druley (Eds.), Substance abuse and psychiatric illness. New York: Pergamon Press. American Psychiatric Association. (1980). Diagnostic ond statistical manual of mental disorders. (3rd ed.). Washington DC: Author. Atkinson, R.M. (1973). Importance of alcohol and drug abuse in psychiatric emergencies. California Medicine, 188, l-4. Boyd, J.H., Burke, J.D., Gruenberg, E., Holzer, C.E., Rae, D.S., George, L.K., Karno, M., Stoltzman, R., McEvoy, L., & Nestadt, Cl. (1984). Exclusion criteria of DSM-III: A study of co-occurrence of hierarchy-free syndromes. Archives General

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Psychiatry, 41, 983-989. Crowley, T.J., Chesluk, D., Dilts, S., & Hart, S. (1974). Drug and alcohol abuse among psychiatric admissions: A multidrug clinical toxicologic study. Archives of General Psychiatry, 30, 13-20. Davis, D.I. (1984). Differences in the use of substances of abuse by psychiatric patients compared with medical patients. Journal of

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Hudson, C.J., & Perkins, S.H. (1984). Panic disorder and alcohol misuse. Journal of Studies on Alcohol, 45, 462-464. McCourt, W.E., Williams, A.F., & Schneider, L. (1971). Incidence of alcohol in a state mental hospital population. Quarterly Jour-

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