The lifetime prevalence of alcohol dependence in South Korea remains higher than other countries. The aim of our study is to identify factors associated with remission from alcohol dependence.
Data from the Korean Epidemiological Catchment Area-Replication (KECA-R) study were used in our study. The Korean version of the Composite International Diagnostic Interview 2.1 (K-CIDI 2.1) was administered. Remission was defined as having no symptom of alcohol dependence for 12 months or longer at the time of the interview. Demographic and clinical variables putatively associated with remission from alcohol dependence were examined by t-test, chi-square-test and logistic regression analysis.
The lifetime prevalence rate of alcohol dependence was 7.0%. Among them, 3.2% of the subjects were diagnosed with active alcohol dependence in the previous 12 months, and 3.8% were found to be in remission. Subjects in 35- to 44-year-old group, not living with partner group, and lower level of educational attainment group were more likely to be in the active alcohol dependence state. Of the comorbid mental disorders, dysthymia, anxiety disorder, nicotine use, and nicotine dependence were more common among the actively alcohol-dependent subjects.
There is considerable level of recovery from alcohol dependence. Attention to factors associated with remission from alcohol dependence may be important in designing more effective treatment and prevention programs in this high-risk population.
Alcohol dependence is a condition characterized by a maladaptive pattern of alcohol consumption that leads to significant distress or impairments in social, occupational, or interpersonal activities. It is a major source of comorbidity in association with affective, anxiety, and personality disorders.
The DSM-IV (American Psychiatric Association, 1995) defines remission from alcohol dependence as when none of the criteria for alcohol dependence or abuse have been met during a period of 12 months or longer. According to several Western studies, the female gender, older age at assessment, being married, more robust social support, younger age at the onset of alcohol dependence, less quantity of drinking, and less severity of drinking all tend to be positively associated with remission.
Alcohol dependence tends to co-occur with other psychiatric disorders much more frequently than would be expected by chance.
Despite the high prevalence of alcohol use disorders in South Korea, factors associated with remission from alcohol dependence have not been examined. In 2006, the Korean Epidemiological Catchment Area (KECA-R) study, a nationwide survey of a representative sample of Korean adults aged 18-64 years, was conducted to investigate the lifetime risk of mental disorders in the general Korean population. In order to gain insight into possible factors influencing risk, severity, and recovery in alcohol dependence, differences in socio-demographic characteristics and psychiatric comorbidities between active and remitted alcohol dependence cases were examined. The aim of the present study is to identify factors associated with remission from alcohol dependence.
Data from the KECA-R study, conducted from July 2006 to April 2007, were used in our study. The KECA-R study was carried out to estimate the prevalence and correlates of psychiatric disorders in Korean adults, which was conducted based on Korean Mental Health Act.
The 2005 Population Census Data at the Korea National Statistical Office was used to create the sampling frames. Twelve catchment areas were selected from a list of all catchment areas in 6 administrative divisions of Korea-Seoul Special city, Gyeonggi-do/Incheon Metropolitan city, Chungcheong-do, Jeolla-do, Gangwon-do, and Gyeongsang-do. A total of 7,968 households in 239 clusters were selected from the 12 catchment areas, using probability proportional to size estimated jointly by the Korean Statistical Association and the Korea National Statistical Office. One individual per selected household was randomly chosen; this was the individual with the earliest birthday without consideration of month or year. From an initially selected 7,968 subjects, aged between 18 and 64 years, a total of 6,510 face-to-face interviews (response rate 81.7%) were conducted, and all subjects completed the Korean version of the Composite International Diagnostic Interview 2.1 (K-CIDI 2.1).
The institutional review board of the Seoul National University College of Medicine approved this study. Each subject was fully informed on study aims and methods before interview completion. Informed consent was obtained prior to participation.
The Korean version of the Composite International Diagnostic Interview 2.1 (K-CIDI 2.1) was administered to each subject by trained lay interviewers. The CIDI
A number of socio-demographic variables were obtained through questions in separate sections of the K-CIDI. Age-at interview was categorized into four groups (≤34 years, 35-44 years, 45-54 years, and ≥55 years). Marital status was categorized into 'Living with partner' and 'Not-living with partner' (partner including not only family but also live-in partner).
Employment status was classified according to whether the subject was currently 1) full- time employed, 2) part-time employed, 3) student or homemaker, or 4) unemployed. Education level was assumed to be orderly and categorized into 1) below a junior high school graduate (0-9 years), 2) senior high school (10-12 years), and 3) university or more (13 years or more).
A total of 78 interviewers with experience in psychiatric epidemiologic surveys and familiar with their area of study were recruited from each catchment area. All interviewers received a 5-day training session that included didactic sessions concerning general interview skills and the interview instruments, mock interviews, and role-playing exercises using standard protocols and training materials developed by the World Health Organization.
Demographic and clinical variables putatively associated with remission from alcohol dependence were examined by basic bivariate analyses, applying the t-test and the chi-square-test. Values of p<0.05 were considered statistically significant. The odds ratios (ORs) and 95% confidence intervals (CIs) of sociodemographic and clinical variables that differentiate active and remitted alcohol dependence were derived from logistic regression analyses, adjusting for age and sex. SPSS (version 18.0) statistical packages were used for the analyses.
The lifetime prevalence rate of alcohol dependence was 7.0% (458/6510).
No differences between age and gender were observed between the two groups. The actively alcohol dependent subjects were more prevalent in the 35-44 years group than the 55-64 years group (adjusted OR 2.74, 95% CI 1.25-5.60). Active alcohol dependence was more common among subjects not living with a partner compared to subjects living with a partner and less common in part-time employed subjects compared to full-time employed subjects. As shown in
The one-year prevalence rates of any DSM-IV psychiatric disorder (except alcohol and nicotine use disorder) were higher in active alcohol dependent subjects than in the remitted ones (24.8 vs. 15.5, p=0.013), with an OR value of 1.96. Dysthymia, any anxiety disorder, agoraphobia, PTSD, nicotine use, and nicotine dependence were significantly more common in the actively alcohol dependent subjects than in the remitted ones. When adjusted for age and sex in a logistic regression model, any anxiety disorder, PTSD, nicotine use and nicotine dependence were significantly associated with active alcohol dependence, with OR values from 1.64 to 8.87. Dysthymia and agoraphobia were not anlayzed in the logistic regression model due to low sample size. There was no significant difference in the mean age of alcohol dependence onset between active and remitted subjects (24.3 years vs. 24.1 years, t=-0.23, n.s., data not shown in Table).
This study is a general population-based study to examine factors associated with remission from alcohol dependence in South Korea. In this study, the rate of 1-year full remission from DSM-IV alcohol dependence was 55%. This rate is comparable to the 1-year full remission rate from DSM-IV alcohol dependence in the U.S. (48%),
Previous studies in Korea indicated that the male gender is a consistent risk factor for alcohol use disorder.
The remission rate from alcohol dependence has been reported to increase with age,
In terms of educational level, subjects who completed 0-9 years education were at increased risk of active alcohol dependence compared to subjects who completed above 13 years education. This may be explained by the statistics that those with lower education are not only in the Agri-fishery industry but also have simple labor jobs in Korea.
We found that people not living with a partner were more common in the active alcohol dependence group than in the remission group. This finding is consistent with previous Western studies,
Interestingly, we found that major depressive disorders were not associated with remission for alcohol dependence but that individuals with any anxiety disorder and dysthymia had a reduced likelihood of achieving remission for alcohol dependence. Previous studies on the impact of major depressive disorder comorbidities in subjects treated for substance use disorder have generated inconsistent results. While some studies found that the likelihood of remission is lower for individuals also diagnosed with a major depressive disorder,
Although depressive symptoms caused by alcohol were not assessed in this study, prior studies have shown that substance-induced and abstinence-related depression are risk factors for alcohol relapse
Of particular note is our finding that comorbidity of post-traumatic stress disorder (PTSD) was largely associated with maintenance of active alcohol dependence. Previous studies have shown that men and women with PTSD more likely to have alcohol dependence compared with the general population
Nicotine use and dependence were also more common in active alcohol dependent subjects than the remitted subjects. The prevalence of nicotine dependence among people with alcohol dependence was over two times higher (45%) than in the general population according to an epidemiological study in the U.S.
There are several limitations to note. First, since this study was a cross-sectional study, we could not examine the causal relations between active alcohol dependence and other psychiatric disorders. In addition, cross-sectional data do not necessarily reflect the course of recovery across time for any given individual. Therefore, longitudinal alcohol epidemiologic survey with a larger sample size would be necessary to examine the natural history of alcohol dependence over time at the individual level. Second, since data collection was restricted to a non-institutionalized population, severely impaired subjects might be under-represented in the sample. According to Korean National Health Insurance database (
Despite these limitations, this report represents an important first step in identifying factors associated with remission from alcohol dependence in Korea. The prevalence of alcohol dependence in Korea is still higher than in other countries in Asia and comparable to western countries. We suggest that our society needs to increase a public awareness to encourage the treatment of alcohol dependence. Such actions may help to lessen the suffering from alcohol dependence on individuals, and reduce the economic burden on society. Our findings, if corroborated by further studies, will help identify high-risk individuals and potentially improve the remission of patients with alcohol dependence.
The authors wish to express their gratitude to 12 local investigators, 79 interviewers, and the Korean Ministry of Health & Welfare for their support and cooperation.
NLWP: not living with partner, PTSD: post-traumatic stress disorder, GAD: generalized anxiety disorder, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, fourth edition
*Fisher exact test. PTSD: post-traumatic stress disorder, GAD: generalized anxiety disorder, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, fourth edition
*factor not present, †put as empty since the sample size were too small to be estimated, ‡statistically significant findings, p<0.05. PTSD: post-traumatic stress disorder, GAD: generalized anxiety disorder, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, fourth edition