PREVALENCE OF ICD-10 HARMFUL USE OF ALCOHOL AND ALCOHOL DEPENDENCE AMONG THE RURAL POPULATION IN UDMURTIA

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1 Alcohol & Alcoholism Vol. 33, No. 3, pp , 1998 PREVALENCE OF ICD-1 HARMFUL USE OF ALCOHOL AND ALCOHOL DEPENDENCE AMONG THE RURAL POPULATION IN UDMURTIA SERGEI PAKRffiV, VEIKO VASAR*, ANU ALUOJA ad JAKOV SHLIK Departmet of Psychiatry, Uiversity of Tartu, Raja 31, EE24 Tartu, Estoia (Received 21 April 1997; i revised form 1 November 1997; accepted 2 November 1997) Abstract A sample of 855 rural adult ihabitats i Udmurtia was iterviewed by the Composite Iteratioal Diagostic Iterview 1:1 (CIDI) to ivestigate the icidece ad prevalece of alcoholrelated disorders. Harmful use of alcohol ad alcohol depedece affected 37.1 of the populatio accordig to ICD-1 ad DSM-ITI-R i a lifetime period. The icidece of alcohol depedece i the previous year was.8 (1.4 i me,.4 i wome). Alcohol-related disorders were more commo i me (72.6) tha i wome (1.3). Correlates of alcohol depedece were sex (69.3 i me, 3.7 i wome), lower educatio (4.1) ad beig divorced i me (77.8). Alcohol depedece had a high comorbidity with social phobia i Udmurt me ad with depressio i Russia me. INTRODUCTION Disorders due to the use of alcohol are commo i the geeral populatio. Differet commuity surveys of the lifetime prevalece of alcohol abuse ad depedece have yielded a wide rage of prevalece rates, from 4 to 23.5 (Robis et al., 1981; Helgaso, 1987; Regier et al., 199; Kessler et al, 1994; Ross, 1995). Frequet comorbid coditios may complicate the course ad treatmet of alcohol-use disorders (Hesselbrock et al., 1985). Alcohol abuse ad depedece, as well as adverse cosequeces thereof, result i large costs to the health care system ad to society (McCrady ad Lagebucher, 1996). Utilizatio of i-patiet resources is ofte related to alcohol-related disorders or illesses (Wallerstedt et al., 1995; McCrady ad Lagebucher, 1996), ad high ad icreasig mortality has bee reported amog alcohol abusers (Serdula et al, 1995; Rya, 1995). Despite their high prevalece i the geeral populatio, alcohol disorders are ofte left udiagosed (Lechky, 1995), ad the prevalece of alcohol-related problems has bee reported to icrease sigificatly durig the last few years of life (Schuckit et al, 1994; Midaik ad Clark, 1995). Author to whom correspodece should be addressed. As stated by Rya (1995), there has bee a disproportioate icrease i deaths from oatural causes, icludig deaths caused predomiatly by alcohol, i the Russia Federatio. The average life expectacy at birth has falle especially sharply for me: by 1993 it had dropped to 59. years, this is below the official retiremet age. The preset report is based o the epidemiological research of metal disorders performed i the rural populatio of Udmurtia. This study examied the prevalece of alcohol abuse ad depedece ad explored relatioships betwee alcoholuse disorders ad various sociodemographic factors. MATERIALS AND METHODS The study was carried out betwee February 1995 ad December 1995 i the Udmurt Republic, a former autoomous Soviet Socialist Republic, which is ow a costituet republic of the Russia Federatio. Udmurtia with its capital Izhevsk lies about 5 km to the west of the Urals ad about 1 km to the east of Moscow. Its populatio comprises two millio people; they are maily Russia though 3 are Udmurts. The Udmurt laguage belogs to the Easter Fiic group of togues. Accordig to the 1989 cesus, the Dowloaded from at Pesylvaia State Uiversity o February 27, Medical Coucil o Alcoholism

2 256 S. PAKRIEV et al. populatio of Udmurtia is more tha 1.6 millio, icludig (3.9) Udmurts, (58.9) Russias ad (1.2) other ethic groups. The majority of the rural populatio form Udmurts (57.8) ad Russias (37.1), followed by other ethic groups (5.1). The studied sample was draw by systematic radom samplig from the lists of rural ihabitats i the age rage 18 to 65 years. The chose group cosisted of 995 idividuals. From these, 78 me ad 24 wome refused to participate i the study ad 38 ihabitats were ot accessible for various reasos. Fially, a total of 855 respodets participated i the study, icludig 487 (57) wome ad 368 (43) me. With regard to ethic backgroud, 569 (67) were Udmurts, 27 (31) Russias, ad 16 (2) others. The Russia versio of the Composite Iteratioal Diagostic Iterview 1:1 (CIDI) was used for detectio of metal disorders. The iterviews were coducted i the Russia laguage, as all the subjects were fluet i Russia. The CIDI (World Health Orgaizatio, 1993a) is a comprehesive ad fully stadardized diagostic iterview desiged for assessmet of metal disorders accordig to the defiitios of both the Diagostic Criteria for Research of ICD- 1 (World Health Orgaizatio, 19936) ad DSM- III-R (America Psychiatric Associatio, 1987). As i our study, alcohol-related disorders showed early idetical prevalece usig ICD-1 ad DSM-III-R, oly data from ICD-1 are preseted. I the iterview, iformatio o the occurrece of ICD-1 diagoses durig the lifetime period was elicited. Several sociodemographic factors, such as geder, age, marital status, ethicity, educatio, ad occupatioal status were derived from the CIDI. Additioal data were collected from the respodets about their livig coditios ad average mothly icome per oe member of the family i US$. Based o the CIDI, two categories of disorders due to use of alcohol (DDUA) were defied: F1.1 harmful use of alcohol (HUA) ad F1.2 depedece sydrome, alcohol (DSA). I the curret study, the diagosis of alcohol abuse did ot iclude those cases which met the criteria for alcohol depedece. For categorizatio of drikig patters durig the previous year, we used a similar classificatio to that of Lara-Catu et al. (199). Seve categories were defied by combiig frequecy ad quatity of itake of ay alcoholic beverage durig the 12 moths prior to the study: (1) frequet heavy driker (FHD): driks five or more driks (oe drik is equal to approximately 9 g of absolute alcohol, a shot glass of vodka, oe glass of wie, or oe bottle of beer) o three or more days a week; (2) frequet high-level driker (FHL): driks five or more driks o oe or two days a week; (3) frequet low-level driker (FLL): driks less tha five driks o oe or more days a week; (4) moderate high-level driker (MHL): driks five or more driks oe to three times a moth; (5) moderate low-level driker (MLL): driks less tha five driks oe to three times a moth; (6) ifrequet driker (IN): driks less tha oce a moth; (7) abstaier: driks less tha oce a year or has ever druk alcoholic beverages. Persoal data of all respodets were coded ad aoymity was guarateed. The CIDI iterview was performed i the home or the workplace of the respodets ad was implemeted i oe sessio i each case. The iterviews were coducted by oe iterviewer who had bee traied i the use of the CIDI. The followig procedures were used for data aalysis: aalysis of variace (ANOVA) was used for compariso of the mea age of oset of use of alcohol, oset of alcohol depedece, ad time betwee the oset of use ad depedece i differet age groups; the Mest was used for comparig the mea umber of driks i a sigle day; the # 2 test was used for assessmet of correlated factors. Epi Ifo, Versio 6 (Dea et al., 1994) was used to calculate the odds ratios. RESULTS As show i Table 1, oly 1.4 of me ad 16.2 of wome i the sample were abstaiers, ad respectively 98.6 of me ad 83.8 of wome were alcohol users. Amog me frequet heavy, frequet high- ad frequet low-level drikers predomiated, i cotrast to wome, amog whom most were moderate low- ad frequet low-level drikers, ad abstaiers (differeces betwee me ad wome were statistically sigificat, P <.1). Drikig patters chaged with age i me. I the age groups 3-39 years ad 4 49 years, frequet heavy drikers prevailed (52.7 ad 51.4 respectively) ad i the Dowloaded from at Pesylvaia State Uiversity o February 27, 214

3 ALCOHOL USE IN RURAL DISTRICT OF UDMURTIA 257 Table 1. Drikig patters i the target sample Drikig patters Total ( = 855) Me ( = 368) Wome ( = 487) Frequet heavy driker Frequet high-level driker Frequet low-level driker Moderate high-level driker Moderate low-level driker Ifrequet driker Abstaier deotes umbers age groups years ad 5-65 years frequet high-level drikers domiated (48.3 ad 33.3 respectively). Alcohol was cosumed almost every day by 2.6 ad at least oce a week by 48.7 of the sample. Table 2 idicates that the proportio of alcoholdepedet persos gradually icreased accordig to the icrease i the frequecy of alcohol cosumptio. Noe of those who cosumed alcoholic beverages less tha oce a moth had alcohol depedece. As show i Table 3, amog respodets with disorders due to use of alcohol, compared with other alcohol users, there were more frequet heavy ad frequet high-level drikers. Most of the respodets without alcohol disorders were moderate low-level drikers, abstaiers, ad ifrequet ad frequet low-level drikers. Amog me with DDUA, there were more frequet heavy (49.4), frequet high- (35.6), ad frequet low- (8.2) level drikers ad amog wome with DDUA, there were more frequet low- (32.), moderate low- (24.) ad frequet high- (18.) level drikers (P <.1). The mea umber of driks i a sigle day (24 h) i me ad wome with DDUA was 8.9 ad 4.8 respectively {P <.1). There were sigificatly more subjects with DSA amog frequet heavy ad frequet high-level Udmurt male drikers tha i the Russia me with the same drikig patter. The mea umber of driks i a drikig day i frequet heavy ad frequet high-level drikers with DSA i Udmurt me was 8.9 ad i Russia me 11.1 (P <.1). The lifetime prevalece rates for ICD-1 alcohol-related disorders are reported i Table 4. The prevalece for DDUA i the total sample was 37.1 (317 cases). The lifetime prevalece was higher for DSA tha for HUA. The lifetime rate of DDUA as well as the lifetime rate of DSA was higher for me tha for wome. The male-female ratio was 7. for DDUA ad 18.7 for DSA. The average age of oset of depedece sydrome for me gradually icreased from 21.9 Table 2. Frequecy of itake of alcoholic beverages amog users with ad without alcohol depedece Frequecy of itake of alcoholic beverages durig the last year Users of alcohol without depedece Users of alcohol depedece with Dowloaded from at Pesylvaia State Uiversity o February 27, 214 Almost every day 3 or 4 days a week 1 or 2 days a week 1 to 3 days a moth Less tha oce a moth deotes umbers.

4 258 S. PAKRIEV et al. Table 3. Drikig patters amog respodets with disorders due to use of alcohol ad amog other alcohol users Drikig patters Usersi of alcohol without 1harmful use or depedece Users of alcohol with harmful use ad/or depedece Frequet heavy driker Frequet high-level driker Frequet low-level driker Moderate high-level driker Moderate low-level driker Ifrequet driker Abstaier Total deotes umbers years i the years age group to 34.9 years i the 5-65 years age group. With the icrease i age, the mea duratio betwee the oset of regular drikig ad the oset of alcohol depedece also gradually icreased from 2.2 years i the years age group to 1.3 years i the 5-65 years age group (Table 5). The miimum ad maximum age of oset of depedece sydrome i the total sample was respectively 17 ad 56 years, with a mea age of 28.9 years (SD = 6.4). I 95 of all cases, the oset of depedece was i the age rage 2-45 years. Table 6 shows icidece rates of DSA (alcohol depedece) durig the last year. The total aual icidece of DSA was 8.2 per 1, 13.6 for me ad 4.1 for wome respectively. Comorbidity of alcohol depedece with other metal disorders is show i Table 7. Comorbidity Patters of alcohol use data are preseted separately for depressio ad social phobia. The umber of subjects i other comorbid diagostic groups was so small that the odds ratios could ot be calculated. More tha 59 of the respodets with lifetime DSA had at least oe other lifetime CIDI diagosis of a metal disorder. The comorbidity of DSA with other disorders was statistically sigificat for social phobia i Udmurt me ad depressive disorders i Russia me. The average age of oset of social phobia was 7.1 years ad i all comorbid cases social phobia started before the oset of alcohol depedece. The sociodemographic correlates of the lifetime diagosis of alcohol depedece (DSA) are examied i Table 8. The lifetime rate for DSA i me was higher i the age group from 4 to 49 years (8.7) ad from 3 to 39 years (78.2). Table 4. Prevalece of alcohol users ad disorders due to use of alcohol accordig to ICD-1 Total <i = 855) SEM (i Lifetime prevalece Me (TI = 368) SEM i Wome = 487) SEM Dowloaded from at Pesylvaia State Uiversity o February 27, 214 Disorders due to use of alcohol (DDUA) Harmful use of alcohol (HUA) Alcohol depedece (DSA) Users of alcohol without harmful use of alcohol or depedece Total alcohol users SEM deotes stadard error of the mea.

5 ALCOHOL USE IN RURAL DISTRICT OF UDMURTIA 259 Age group (years) Table 5. Oset of use of alcohol, alcohol depedece ad mea duratio betwee them i me Mea age (years) Oset of use alcohol* of SEM Mea age (years) Oset of alcohol depedece** SEM Mea duratio*** Years SEM (a) (b) 3-39 (c) 4-49 (d) 5-65 Total * Results of ANOVA: P* b =.2; P* <.1; P* <.1. ** Results of ANOVA: differeces betwee each group are sigificat at the P <.1 level. *** Mea duratio betwee oset of regular drikig ad oset of alcohol depedece; results of ANOVA: /** =.5; P* <.1; P"" <.1; F** =.5; P M <.1; P ca =.27. Higher tha average prevalece of DSA was also foud amog the divorced (lifetime 77.8) ad married (72.6) me. I the total group, less educated subjects showed higher rates of depedece. Workers ad uemployed subjects were more likely to have lifetime alcohol depedece tha other occupatioal groups. The highest rate of DSA occurred i uemployed me. There were o associatios betwee DSA rate ad ethicity. There were o associatios betwee DSA ad icome: the average mothly icome for each member of the family of persos with DSA was about US$25.2 ad the average mothly icome for each member of the family of persos without DSA was about US$25.5. Alcohol depedece Age group (years) («) 3-39 () 4-49 («) 5-65 («) Total («) 4 (224) (287) 3 (26) (138) 7 (855) Table 6. Oe-year icidece rate of alcohol depedece Both sexes (89) (11) 3 (19) (6) 5 (368) (), deotes the total umber of persos i the respective age group was ot associated with housig space per member of the family. Oe hudred ad sixty-four respodets with DSA had tried to stop their drikig, but oly eight of them (remissio rate 4.9) were abstiet for more tha 12 moths. DISCUSSION Oe limitatio of the preset study was i the selectio of respodets, which allows coclusios for rural populatios oly. As the umber of villages studied was small, we could ot maitai the exact ethic proportios of the rural populatio. Aother problem was the total umber of Me ( = 368) (135) (177) (97) (78) 2 (487) Wome ( = 487) Dowloaded from at Pesylvaia State Uiversity o February 27, 214

6 26 S. PAKRTEV et al. Table 7. Comorbidity of alcohol depedece (lifetime) Comorbid disorder Me Wome from subjects with alcohol depedece Odds ratio* 95 CI from subjects with alcohol depedece Odds ratio* 95 CI Depressio Udmurts Russias Social phobia Udmurts Russias Ay other disorder Udmurts Russias ** 2.29** ** ^ * Ratio of the odds of havig the comorbid disorder i the alcohol depedece group to the odds i the o-depedece group. ** Statistically sigificat odds ratio. CI deotes cofidece iterval. subjects, which limited the possibilities of studyig risk factors i small subgroups, particularly data o icidece. The frequecy of itake of alcohol obtaied i our study (2.6 for almost-every-day cosumers ad 48.7 for at least oce-a-week cosumers) is similar to the results of other studies 3 daily drikers reported by Bar et al. (1989) ad 51.3 at least oce-a-week drikers reported by Alvares ad Del-Rio (1994). At the same time, drikig patters foud i our subjects are cosiderably differet from the data of other studies. The proportio of frequet heavy ad frequet highlevel drikers foud i our study is more tha six times higher tha that show by Lara-Catu et al. (199). Less tha 1 of the total sample were abstaiers, which is more tha five times less tha the results reported by Bar et al. (1989), Lara- Catu et al. (199), ad Dawso et al. (1995), although it is similar to the results obtaied by Helzer ad Pryzbeck (1988) of 11. As expected, higher frequecy of alcohol cosumptio ad higher quatities of cosumed beverages were foud amog respodets with disorders due to use of alcohol, compared to drikers without alcohol disorders, which is cosistet with other studies (Lara-Catu et al, 199; York, 1995). Accordig to data from our study, alcoholrelated metal disorders are highly prevalet i the rural populatio i Udmurtia. The lifetime prevalece rate of harmful alcohol use ad depedece is 37.1, which is over twice as high as results obtaied i other commuity studies (Robis et al, 1981; Helgaso, 1987; Regier et al, 199; Ross, 1995). However, our fidigs are closer to the 23.5 prevalece rate for alcohol abuse ad depedece i the Natioal USA Comorbidity Survey (Kessler et al, 1994), which also used the CIDI. Our results cofirm the geeral fidig that me use alcohol i greater quatities ad with higher frequecy tha wome (Lara-Catu et al, 199; York ad Welte, 1994) ad that males have a higher prevalece of alcohol-related disorders (Kessler et al., 1994; Arolt et al, 1995; Ross, 1995). The lifetime prevalece rate of harmful use of alcohol ad alcohol depedece amog me was more tha twice as high as the rate obtaied i other commuity studies (Yamamoto et al., 1993; Kessler et al., 1994; Ross, 1995) ad over seve times higher tha i wome i our study. Although all studies report a higher prevalece of alcohol-related disorders i me, the sex ratio varies cosiderably, from 1.77 (Bromet et al., 199), 2.2 (Kessler et al., 1994), 4 (Ross, 1995) to 14.1 (Yamamoto et al, 1993). The lifetime prevalece rate of alcohol depedece amog me is over 18 times higher tha i wome i our study. Although the higher prevalece of alcohol depedece i me tha i wome is a expected fidig, the sex ratio is remarkably higher tha i other studies, for Dowloaded from at Pesylvaia State Uiversity o February 27, 214

7 ALCOHOL USE IN RURAL DISTRICT OF UDMURTIA 261 Table 8. Lifetime prevalece of alcohol depedece () amog rural ihabitats accordig to related factors Factor Total ( = 855) Me ( = 368) Wome ( = 487) SE SE SE Total group f-value Age (years) P Marital status Married Divorced Never married P Ethicity Russias Udmurts P Basic educatio Higher Secodary Lower secodary P Occupatioal status Worker Employee Retired Uemployed *** *** * NS ** NS NS NS NS ** NS ** *** * *** SE = stadard error; * P <.5; ** P <.1; *** P <.1. NS = ot sigificat. istace 2.45 (Kessler et al, 1994), 4.1 (Ross, 1985; Ross etal., 1988; Regieref al, 199; Helzer 1995), 5 (Leug et al., 1993), 5.77 (Arolt et al, etal, 1991; Ross, 1995). Alcohol depedece has 1995). Although the icidece of alcohol depe- bee foud to be comorbid with depressio dece sydrome i the previous year is also more (Spaer et al., 1994; Davidso, 1995; Grat ad tha three times as high i me tha i wome, Harford, 1995; Ross, 1995) ad social phobia this sex differece is ot so extreme as i the (Judd, 1994; Dick et al., 1994; Ross, 1995). Our prevalece fidigs. Compariso of the sex ratio results showed a statistically sigificat associaof prevalece ad icidece suggests that morbid- tio betwee alcohol-depedece sydrome ad ity amog wome seems to be icreasig. social phobia i Udmurt me ad betwee The aalysis of morbidity by age groups alcohol-depedece sydrome ad depressio i idicates that the age of oset of depedece is Russia me. Depressio was i the majority of decreasig ad that the duratio betwee the start cases secodary to alcohol abuse, as also reported of regular use ad the oset of depedece is by Hasi et al. (1988). shorteig. This has also bee revealed i other It seems that comorbid disorders are more studies (Robis ad Regier, 1991; Kessler et al, depedet o ethicity tha o alcohol depe- 1994). dece itself. Our fidigs (upublished data from The preset fidigs show that the majority of the same survey) showed that the lifetime idividuals with alcohol depedece have some prevalece of social phobia i Udmurts is more comorbid disorder; this is cosistet with a tha three times higher i compariso with other umber of previous studies (Hesselbrock et al, studies (Wittche et al, 1992; Judd, 1994; Dick et Dowloaded from at Pesylvaia State Uiversity o February 27, 214

8 262 S. PAKRIEV et al. al., 1994). The oset of social phobia geerally preceded that of alcohol disorders, which is i accordace with several other studies (Kusher et al, 199; Ross, 1995; Magee et al, 1996). As oted by Kusher et al. (199), people sufferig from axiety have a icliatio to cosume alcohol to relieve their symptoms, ad i social phobia alcohol problems ca arise from the attempts to self-medicate the symptoms of axiety. Ross (1995) also poited out that social phobia icreases the odds of subsequet alcohol depedece. As oted by Richma ad Rospeda (1992), social-relatioal deficits ad icapacity to form social support are predictive of alcohol abuse for stress reductio purposes. Thus, social phobia could be a cultural feature of the Udmurt me which icreases the risk of alcohol depedece ad may partly explai the high rate of alcohol abuse ad depedece i Udmurts. Although the ature of comorbidity betwee alcohol depedece ad axiety disorders is ot uequivocal (see for istace Schuckit ad Hesselbrock, 1994), our data support the opiio that social phobia is primary to alcohol depedece. Our study revealed a very low remissio rate i subjects with alcohol depedece. Oly 4.9 amogst those who ever tried to stop their drikig were abstiet for more tha 12 moths, which is more tha 12 times less tha the 63 reported by Leug et al. (1993). Brow et al. (1995) suggest that high vulerability to alcohol relapse reflects poor psychosocial domais copig skills, selfefficacy, social support, ad perceived ability to tolerate relapse-risk situatios. There were o associatios betwee rates of alcohol depedece ad ethicity accordig to our fidigs; however, there were sigificat differeces i alcohol cosumptio patters i the Udmurt ad Russia me. There were more Udmurts with depedece tha Russias amog frequet heavy ad frequet high-level male drikers ad at the same time Udmurts cosumed less alcohol tha Russia me. Ethic differeces i alcohol cosumptio behaviour ca be better uderstood by a social-psychological, rather tha a biomedical, approach (Neff, 1993; Yamamoto et al., 1993; Li ad Roseblood, 1994; Herd, 1994). However, our data do ot permit a defiite coclusio about the role of physiological or psychosocial factors i the differeces of alcohol cosumptio patters betwee Udmurts ad Russias. A high prevalece of alcohol depedece amog the umarried was reported by Bromet et al. (199) ad a higher prevalece of comorbid alcohol abuse/depedece amog the ever-married was reported by Ross (1995). I our study, the highest rate of alcohol depedece was obtaied i divorced ad married me but this may be the ifluece of age as the ever-married maily beloged to the yougest group. The lifetime rates for alcohol depedece i me were higher i middle age which is cosistet with prior research (York, 1995). Lower lifetime prevalece i the oldest age-group suggests that the prevalece of alcohol depedece has icreased durig recet decades. Other putative reasos could be dimiished recall of early drikig problems by older respodets or icreased reluctace to ackowledge such troubles (Ross, 1995). Possible high mortality rates amog older alcoholics could also cotribute to the decrease i lifetime prevalece with age (Ross, 1995). The icreased rate of alcohol depedece foud i uemployed me is cosistet with other studies (Herd, 1994; Midaik ad Clark, 1995). The majority of studies have reported a egative relatioship betwee icome ad alcohol depedece (Robis ad Regier, 1991; Kessler et al., 1994), whereas there were o associatios betwee alcohol depedece ad icome i our study. However, it must be oted that the majority of the rural populatio i Udmurtia has a low icome. Similarly to other studies, we foud a higher lifetime prevalece of depedece amog the lower-educated group (Holzer et al., 1986; Bruce et al., 1991). This is somewhat differet from the results of the Natioal USA Comorbidity Survey (Kessler et al., 1994), which showed that lifetime substace-use disorder is sigificatly higher i the middle-educatio subsamples tha amog those with either the lowest or highest educatio. I coclusio, the results of the preset study clearly idicate that the pheomeo of drikig is a serious public health cocer i Udmurtia, ad there is therefore a eed for major public ad medical itervetios. Ackowledgemets We thak all study participats for their cooperatio. The Fiish M.A. Castre Society supported the study fiacially. Dowloaded from at Pesylvaia State Uiversity o February 27, 214

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