Subtypes of alcohol dependence: Predicting relapse and death following treatment

Long-term heavy drinking and alcohol dependence are linked to multiple health problems, including premature death. The risk of serious harm is higher for women than men, and also depends on the person’s current level of drinking. However, it is not known if other factors, such as previous drinking history and co-existing psychiatric conditions, might also contribute to early death in people with alcohol dependence. One way to evaluate the impact of these factors is to group patients based on clusters of characteristics and assess outcomes in each group. Alcohol dependence ‘subtypes’ have previously been used to group patients for treatment planning purposes, but have not been assessed for their role in predicting long-term outcomes of alcohol dependence.  A new study, reported in Alcoholism: Clinical and Experimental Research, has evaluated four alcohol dependence subtypes as predictors of relapse in the year after treatment, and as predictors of mortality over 36 years of follow-up.

Data were from 232 men and 84 women who had inpatient treatment for alcohol dependence in Connecticut in the early 1980s. Detailed information collected at admission – on alcohol use patterns, related health problems, history of psychiatic disorders, drinking consequences, and family history – was used to derive four patient subtypes: ‘High-risk, high-severity’ (HR/HS, typically younger patients with a high risk, early-onset alcohol dependence, and a high level of psychiatric comorbidity); ‘low risk, low severity’ (LR/LS; older patients, with low risk, late-onset alcohol dependence, low alcohol involvement, and minimal psychiatric comorbidity); ‘internalisers’ (mainy female, with high alcohol involvement and high levels of depression and anxiety disorder), and ‘externalisers’ (mostly males, with moderate/high alcohol involvement and high levels of outward-directed behavioral issues and/or antisocial personality disorder). A second interview conducted one year post-treatment assessed whether patients had resumed regular (at least weekly) drinking. More recently, the researchers have used public records to identify deaths in the 36 years since treatment.

The data showed that most patients did return to regular alcohol use during the first year after treatment, with the externalizer and HR/HS subtypes the most likey to do so. After 36 years, more than two-thirds (68.4%) of patients had died, with a higher death rate among those who had resumed drinking within one year than among one-year abstainers. The mortality rate for all four patient subtypes was higher than that of the general (non-alcohol-dependent) population, after standardizing for age. However, again the risk differed across the subtypes, such that the HR/HS and externaliser subtypes were at greatest risk of early death. Women had a much higher mortality risk than men, both overall and within each subtype.  

The findings support the clinical value of alcohol dependence subtypes, defined in part by psychiatric conditions, for studying alcohol use outcomes over time. Further, the results could help health professionals target monitoring efforts and post-treatment interventions to those patients at greatest risk for resuming regular drinking and for early death. The findings also confirm the very high risk facing alcohol-dependent women.

Subtypes of alcohol dependence and 36-year mortality. M.N. Hesselbrock, V.M. Hesselbrock, G. Chan, F. Del Boca, K. Chartier (pages xxx)

ACER-20-4414.R1

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