Alcohol abstinence and mortality in a general population sample of adults in Germany: A cohort study.

BACKGROUND: Evidence suggests that people who abstain from alcohol have a higher mortality rate than those who drink low to moderate amounts. However, little is known about factors that might be causal for this finding. The objective was to analyze former alcohol or drug use disorders, risky drinking, tobacco smoking, and fair to poor health among persons who reported abstinence from alcohol drinking in the last 12 months before baseline in relation to total, cardiovascular, and cancer mortality 20 years later. METHODS AND FINDINGS: A sample of residents aged 18 to 64 years had been drawn at random among the general population in northern Germany and a standardized interview conducted in the years 1996 to 1997. The baseline assessment included 4,093 persons (70.2% of those who had been eligible). Vital status and death certificate data were retrieved in the years 2017 and 2018. We found that among the alcohol-abstinent study participants at baseline (447), there were 405 (90.60%) former alcohol consumers. Of the abstainers, 322 (72.04%) had met one or more criteria for former alcohol or drug dependence or abuse, alcohol risky drinking, or had tried to cut down or to stop drinking, were daily smokers, or self-rated their health as fair to poor. Among the abstainers with one or more of these risk factors, 114 (35.40%) had an alcohol use disorder or risky alcohol consumption in their history. Another 161 (50.00%) did not have such an alcohol-related risk but were daily smokers. The 322 alcohol-abstinent study participants with one or more of the risk factors had a shorter time to death than those with low to moderate alcohol consumption. The Cox proportional hazard ratio (HR) was 2.44 (95% confidence interval (CI), 1.68 to 3.56) for persons who had one or more criteria for an alcohol or drug use disorder fulfilled in their history and after adjustment for age and sex. The 125 alcohol-abstinent persons without these risk factors (27.96% of the abstainers) did not show a statistically significant difference from low to moderate alcohol consumers in total, cardiovascular, and cancer mortality. Those who had stayed alcohol abstinent throughout their life before (42; 9.40% of the alcohol-abstinent study participants at baseline) had an HR 1.64 (CI 0.72 to 3.77) compared to low to moderate alcohol consumers after adjustment for age, sex, and tobacco smoking. Main limitations of this study include its reliance on self-reported data at baseline and the fact that only tobacco smoking was analyzed as a risky behavior alongside alcohol consumption. CONCLUSIONS: The majority of the alcohol abstainers at baseline were former alcohol consumers and had risk factors that increased the likelihood of early death. Former alcohol use disorders, risky alcohol drinking, ever having smoked tobacco daily, and fair to poor health were associated with early death among alcohol abstainers. Those without an obvious history of these risk factors had a life expectancy similar to that of low to moderate alcohol consumers. The findings speak against recommendations to drink alcohol for health reasons.

Longitudinal measurement invariance of the patient health questionnaire in a German sample.

BACKGROUND: The Patient Health Questionnaire-8 (PHQ-8) is a screening questionnaire of depressive symptoms. However, it is unknown whether it is equivalent across time and between groups of individuals. The aim of our paper was to test whether the PHQ-8 has the same meaning in two groups of individuals over time. METHODS: Primary care patients were proactively recruited from three German cities. PHQ-8 data from a baseline assessment (n = 588), two assessments during the intervention (n = 246/225), and a six (n = 437) and 12 months (n = 447) follow-up assessment were first used to examine the factor structure of the PHQ-8 by confirmatory factor analysis (CFA). The best fitting factor solution was then used to test longitudinal invariance across time and between intervention and control group by Multiple Group CFA. RESULTS: A two-factor structure consistently showed the best model fit. Only configural longitudinal invariance was evidenced when the baseline assessment was included in the analysis. Without the baseline assessment, strict longitudinal invariance was shown across the intervention and the follow-up assessments. Scalar invariance was established between the intervention and control group for the baseline assessment and strict invariance between groups and across the 6- and 12-month follow-up assessments. CONCLUSIONS: The lack of longitudinal invariance might be attributed to various differences between the baseline assessments and all following assessments, e.g., assessment mode (iPad vs telephone), potential changes in symptom perception, and setting. TRIAL REGISTRATION: DRKS0001163 5, date of trial registration: 20.01.2017; DRKS00011637 , date of trial registration: 25.01.2017.

Latent alcohol use patterns and their link to depressive symptomatology in medical care patients.

AIMS: To investigate latent patterns of alcohol use and bingeing by gender and their association with depressive symptom severity and individual depressive symptoms. DESIGN: Cross-sectional data were collected from January 2017 to March 2018 as part of a joint screening recruiting for different intervention studies. SETTING: Ambulatory practices and general hospitals from three sites in Germany. PARTICIPANTS: A total of 5208 male and 5469 female proactively recruited alcohol users aged 18-64 years. MEASUREMENTS: Frequency and typical quantity of alcohol use, frequency of bingeing, alcohol-related problems (assessed by the Alcohol Use Disorder Identification Test); depressive symptom severity, individual depressive symptoms (assessed with the Patient Health Questionnaire-8); and socio-demographics and health-related variables. FINDINGS: Latent categorical analysis identified six patterns of alcohol use, with the majority of patients engaging in 'light use plus no or occasional bingeing' (males: 41.85%; females: 64.04%), followed by 'regular use plus occasional bingeing' (males: 34.03%; females: 16.17%). Multinomial logistic regression analyses (three-step approach with correction for classification uncertainty, as implemented in the Mplus R3STEP command) controlling for socio-demographics and health-related variables revealed that severity of depressive symptoms was positively associated with 'frequent use plus frequent bingeing' when compared with 'light use plus no or occasional bingeing' [relative risk ratio (RRR)male  = 1.07, 95% confidence interval (CI) = 1.03-1.11; RRRfemale  = 1.09, 95% CI = 1.04-1.14]. Severity of depressive symptoms was negatively associated with 'regular use plus occasional bingeing' for males (RRRmale  = 0.98, 95% CI = 0.95-1.00) and positively with 'occasional use plus occasional bingeing' for females (RRRfemale  = 1.03, 95% CI = 1.01-1.05) when compared with 'light use plus no or occasional bingeing'. Individual depressive symptoms were differentially associated with alcohol use patterns, with depressed mood, poor appetite or overeating, feelings of worthlessness or guilt and psychomotor agitation or retardation, being especially pronounced in the 'frequent use plus frequent bingeing' class (RRRsmale  = 1.72-2.36; RRRsfemale  = 1.99-2.17). CONCLUSIONS: Patterns of 'frequent alcohol use plus frequent bingeing' and 'occasional alcohol use plus occasional bingeing' appear to have positive associations with depression when compared with 'light alcohol use plus no or occasional bingeing'.

Use of machine learning to classify adult ADHD and other conditions based on the Conners' Adult ADHD Rating Scales.

A reliable diagnosis of adult Attention Deficit/Hyperactivity Disorder (ADHD) is challenging as many of the symptoms of ADHD resemble symptoms of other disorders. ADHD is associated with gambling disorder and obesity, showing overlaps of about 20% with each diagnosis. It is important for clinical practice to differentiate between conditions displaying similar symptoms via established diagnostic instruments. Applying the LightGBM algorithm in machine learning, we were able to differentiate subjects with ADHD, obesity, problematic gambling, and a control group using all 26 items of the Conners' Adult ADHD Rating Scales (CAARS-S: S) with a global accuracy of .80; precision (positive predictive value) ranged between .78 (gambling) and .92 (obesity), recall (sensitivity) between .58 for obesity and .87 for ADHD. Models with the best 5 and best 10 items resulted in less satisfactory fits. The CAARS-S seems to be a promising instrument to be applied in clinical practice also for multiclassifying disorders displaying symptoms resembling ADHD.

Screening and assessment tools for gaming disorder: A comprehensive systematic review.

The inclusion of gaming disorder (GD) as an official diagnosis in the ICD-11 was a significant milestone for the field. However, the optimal measurement approaches for GD are currently unclear. This comprehensive systematic review aimed to identify and evaluate all available English-language GD tools and their corresponding evidence. A search of PsychINFO, PsychArticles, ScienceDirect, Scopus, Web of Science, and Google Scholar identified 32 tools employed in 320 studies (N = 462,249 participants). The evaluation framework examined tools in relation to: (1) conceptual and practical considerations; (2) alignment with DSM-5 and ICD-11 criteria; (3) type and quantity of studies and samples; and (4) psychometric properties. The evaluation showed that GD instrumentation has proliferated, with 2.5 tools, on average, published annually since 2013. Coverage of DSM-5 and ICD-11 criteria was inconsistent, especially for the criterion of continued use despite harm. Tools converge on the importance of screening for impaired control over gaming and functional impairment. Overall, no single tool was found to be clearly superior, but the AICA-Sgaming, GAS-7, IGDT-10, IGDS9-SF, and Lemmens IGD-9 scales had greater evidential support for their psychometric properties. The GD field would benefit from a standard international tool to identify gaming-related harms across the spectrum of maladaptive gaming behaviors.

DSM-5 Internet gaming disorder among a sample of Mexican first-year college students.

BACKGROUND AND AIMS: DSM-5 includes Internet gaming disorder (IGD) as a condition for further study. While online and offline gaming may produce undesired negative effects on players, we know little about the nosology of IGD and its prevalence, especially in countries with emerging economies. METHODS: A self-administered survey has been employed to estimate prevalence of DSM-5 IGD and study the structure and performance of an instrument in Spanish to measure DSM-5 IGD among 7,022 first-year students in 5 Mexican universities that participated in the University Project for Healthy Students (PUERTAS), part of the World Health Organization's World Mental Health International College Student Initiative. RESULTS: The scale for IGD showed unidimensionality with factor loadings between 0.694 and 0.838 and a Cronbach's α = .816. Items derived from gaming and from substance disorders symptoms mixed together. We found a 12-month prevalence of IGD of 5.2% in the total sample; prevalence was different for males (10.2%) and females (1.2%), but similar for ages 18-19 years (5.0%) and age 20+ (5.8%) years. Among gamers, the prevalence was 8.6%. Students with IGD were more likely to report lifetime psychological or medical treatment [OR = 1.8 (1.4-2.4)] and any severe role impairment [OR = 2.4 (1.7-3.3)]. Adding any severe role impairment to the diagnostic criteria decreased the 12-month prevalence of IGD to 0.7%. DISCUSSION AND CONCLUSIONS: Prevalence of DSM-5 IGD and the performance of diagnostic criteria in this Mexican sample were within the bounds of what is reported elsewhere. Importantly, about one in every seven students with IGD showed levels of impairment that would qualify them for treatment under DSM-5.

Diagnostic performance of the Alcohol Use Disorders Identification Test (AUDIT) in detecting DSM-5 alcohol use disorders in the General population.

OBJECTIVE: The Alcohol Use Disorders Identification Test (AUDIT) is an established screening questionnaire for the detection of at-risk drinking and possible alcohol use disorders (AUD) according to the Diagnostic and Statistical Manual of Mental Disorders - fourth edition (DSM-IV). But there are still no comparable results on the diagnostic performance regarding the new criteria for AUD in the Diagnostic and Statistical Manual of Mental Disorders - fifth edition (DSM-5), especially taking account of possible gender differences. We evaluated the performance of the full AUDIT and the consumption questions (AUDIT-C) in screening for DSM-5 AUD and at-risk drinking. METHOD: Data from the study Transitions in Alcohol Consumption and Smoking (TACOS) is used to analyze the area under the receiver-operating characteristic curve, sensitivity, and specificity of the AUDIT and the AUDIT-C in the general population of northern Germany. DSM-5 AUD and at-risk drinking were assessed with the Munich-Composite Diagnostic Interview and used as gold standards. RESULTS: The best balance between sensitivity and specificity is achieved at a score of 5 for men and 4 for women. High severity, according to DSM-5, were associated with higher cut-offs. CONCLUSIONS: Both AUDIT versions are accurate in the screening for DSM-5 AUD. Since the proposed cut-offs do not differ from the optimal screening cut-offs for DSM-IV disorders, current screening procedures should not face major changes.

Measurement invariance of the alcohol use disorders identification test: Establishing its factor structure in different settings and across gender.

INTRODUCTION: The Alcohol Use Disorders Identification Test (AUDIT) is an internationally well-established screening tool for the assessment of hazardous and harmful alcohol consumption. To be valid for group comparisons, the AUDIT should measure the same latent construct with the same structure across groups. This is determined by measurement invariance. So far, measurement invariance of the AUDIT has rarely been investigated. We analyzed measurement invariance across gender and samples from different settings (i.e., inpatients from general hospital, patients from general medical practices, general population). METHODS: A sample of n = 28,345 participants from general hospitals, general medical practices and the general population was provided from six studies. First, we used Confirmatory Factor Analysis (CFA) to establish the factorial structure of the AUDIT by comparing a single-factor model to a two-factor model for each group. Next, Multiple Group CFA was used to investigate measurement invariance. RESULTS: The two-factor structure was shown to be preferable for all groups. Furthermore, strict measurement invariance was established across all groups for the AUDIT. CONCLUSION: A two-factor structure for the AUDIT is preferred. Nevertheless, the one-factor structure also showed a good fit to the data. The findings support the AUDIT as a psychometrically valid and reliable screening instrument.

Type of gambling as an independent risk factor for suicidal events in pathological gamblers.

Individuals with pathological gambling have an increased risk for suicidal events. Additionally, the prevalence of comorbid psychiatric disorders is high among pathological gamblers. This study analyzes whether the type of gambling is associated with suicidal events in pathological gamblers independently from comorbidity. Participants were recruited in 4 different ways: via random telephone sample from the general population, via individual invitation for study participation in gambling locations, through various media and the distribution of a leaflet in various settings, and via inpatient treatment facilities for pathological gambling. The final sample included 442 participants with a lifetime diagnosis of pathological gambling. A standardized clinical interview was conducted. High financial losses were associated with suicidal events (odds ratio [OR] = 1.94, 95% 95% confidence interval [CI], [1.11, 3.37]), as were mood disorders (OR = 7.70, 95% CI, [4.44, 13.37]) and female gender (OR = 2.52, 95% CI, [1.20, 5.28]). Gambling on electronic gambling machines in gambling halls or bars was associated with increased odds of suicidal events (OR = 2.94, 95% CI, [1.38, 6.24]). Other types of gambling, such as casino games or betting on sports, or the number of DSM-IV criteria for pathological gambling were not associated independently with suicidal events. Our findings suggest that gambling on electronic gambling machines in gambling halls or bars is associated with suicidal events in pathological gamblers independently of comorbidity. This result shows that the type of gambling needs to be considered as a relevant factor in gambling research.

Suicidal events among pathological gamblers: the role of comorbidity of axis I and axis II disorders.

The risk for suicidal ideation and suicide attempts among pathological gamblers is high compared to the general population. Little is known about the interplay of Axis I and Axis II disorders, severity of gambling disorder, and suicidal ideation and suicide attempts. The study aims to address this linkage. The sampling design of the study "Pathological Gambling and Epidemiology" (PAGE) included four recruitment channels: general population, gambling locations, project telephone hotline, and in-patient treatment for pathological gambling. A total of 442 study participants with lifetime pathological gambling received a clinical interview. The multivariate analysis showed mood disorders (Relative Risk Ratio, RRR=5.14, 95%-Confidence Interval, CI=2.91-9.07), substance use disorders (RRR=1.73, CI=1.02-2.94), and early onset of gambling disorder (RRR=0.96, CI=0.93-0.99) to be associated with suicidal ideation. Suicidal attempts were associated with female sex (RRR=3.58, CI=1.56-8.19), mood disorders (RRR=11.92, CI=4.70-30.26), and Cluster B personality disorders (RRR=2.40, CI=1.13-5.10). Among study participants with suicide attempts, more had a Cluster B personality disorder than among participants with ideation solely (RRR=3.08, CI=1.48-6.40). Among this large mixed sample of pathological gamblers, high proportions of individuals with suicidal events, multi-morbidity on Axis I, and a strong linkage to Cluster B personality disorders were found.

Association of sociodemographic, psychopathological and gambling-related factors with treatment utilization for pathological gambling.

BACKGROUND/AIMS: Only a small percentage of pathological gamblers utilizes professional treatment for gambling problems. Little is known about which social and gambling-related factors are associated with treatment utilization. The aim of this study was to look for factors associated with treatment utilization for pathological gambling. METHODS: The study followed a sampling design with 3 different recruitment channels, namely (1) a general population-based telephone sample, (2) a gambling location sample and (3) a project telephone hotline. Pathological gambling was diagnosed in a telephone interview. Participants with pathological gambling (n=395) received an in-depth clinical interview concerning treatment utilization, comorbid psychiatric disorders and social characteristics. RESULTS: Variables associated with treatment were higher age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.03-1.08], an increased number of DSM-IV criteria for pathological gambling (OR 1.34, 95% CI 1.06-1.70), more adverse consequences from gambling (OR 1.10, 95% CI 1.03-1.16) and more social pressure from significant others (OR 1.17, 95% CI 1.07-1.27). Affective disorders were associated with treatment utilization in the univariate analysis (OR 1.81, 95% CI 1.19-2.73), but multivariate analysis showed that comorbid psychiatric disorders were not independently associated. CONCLUSION: These results indicate that individuals with more severe gambling problems utilize treatment at an older age when more adverse consequences have occurred. Further research should focus on proactive early interventions.

Factor structure of the compulsive internet use scale.

An important step in Internet addiction research is to develop standardized instruments for assessing Internet addiction-related symptoms. The Compulsive Internet Use Scale (CIUS) is a promising brief questionnaire. The aim of this study was to examine the factor structure of a German version of the CIUS with confirmatory factor analysis in a general population sample. In addition, the best fitting structure was tested for factorial invariance across sex, age, education level, and weekly Internet use. We used a weighted general population sample (N=8,132) of 14-64 years olds spending at least 1 hour online for private purposes per typical working or weekend day. Findings include that a one-factor model was found to fit well. It was invariant across sex, age, education level, and weekly Internet use. The findings support the validity of the CIUS as a short screening instrument.

Assessment of problematic internet use by the Compulsive Internet Use Scale and the Internet Addiction Test: a sample of problematic and pathological gamblers.

This study aims to analyze psychometric properties and validity of the Compulsive Internet Use Scale (CIUS) and the Internet Addiction Test (IAT) and, second, to determine a threshold for the CIUS which matches the IAT cut-off for detecting problematic Internet use. A total of 292 subjects with problematic or pathological gambling (237 men, 55 women) aged 14-63 years and with private Internet use for at least 1 h per working or weekend day were recruited via different recruitment channels. Results include that both scales were internally consistent (Cronbach's α=0.9) and had satisfactory convergent validity (r=0.75; 95% CI 0.70-0.80). The correlation with duration of private Internet use per week was significantly higher for the CIUS (r=0.54) compared to the IAT (r=0.40). Among all participants, 25.3% were classified as problematic Internet users based on the IAT with a cut-off≥40. The highest proportion of congruent classified cases results from a CIUS cut-off ≥18 (sensitivity 79.7%, specificity 79.4%). However, a higher cut-off (≥21) seems to be more appropriate for prevalence estimation of problematic Internet use.

Comorbid Axis I-disorders among subjects with pathological, problem, or at-risk gambling recruited from the general population in Germany: results of the PAGE study.

The aim of the present study was to analyze comorbid Axis I-disorders in a sample of individuals with at-risk, problem, and pathological gambling. A number of 164 adult gamblers derived from a random sample of 15,023 individuals were compared with a general population sample. The lifetime prevalence of any psychiatric disorder was 93.6% among pathological (five-10 criteria), 83.5% among problem (three or four criteria), and 81.0% among at-risk gamblers (one or two criteria). Substance use disorders were the most common comorbid disorders in gamblers. Logistic regression analyses revealed elevated odds ratios for having a comorbid disorder in at-risk (Conditional Odds Ratio (COR) 3.5, Confidence Interval (CI) 2.6-4.6), problem (COR 4.9, CI 3.3-7.3), and pathological gamblers (COR 4.6, CI 3.0-6.9) compared to the general population. No significant differences were found between at-risk and problem gamblers or problem and pathological gamblers. Compared to at-risk gamblers, pathological gamblers showed elevated rates of comorbid substance use disorders. The data suggest a linear association between gambling disorder severity and comorbid Axis I-disorders. In conclusion, comorbid disorders are very prevalent in individuals with gambling problems. Even at-risk gamblers with one or two DSM-IV criteria show high rates of Axis I-disorders. Therefore, this group should be included in further studies on problematic gambling.

Prevalence of dependence on prescription drugs and associated mental disorders in a representative sample of general hospital patients.

OBJECTIVES: The aim of this study was to determine the prevalence of dependence on prescription drugs (DPD) and associated comorbid disorders in consecutive general hospital inpatients. METHODS: The sample consisted of 952 volunteer patients (age range, 18 to 64 years) in a German general hospital. The screening instrument was a self-administered questionnaire. A personal interview containing the Structured Clinical Interview for DSM-IV (SCID, Axis I) was used to evaluate positive screening results and to diagnose comorbid disorders. RESULTS: The current prevalence of DPD was 4.7% [95% confidence interval (CI), 3.40-6.18; n=45). The current prevalence of single sedative dependence was 1.4% (95% CI, 0.62-2.14); of single hypnotic dependence, 1.2% (95% CI, 0.47-1.87); and of painkillers, 1.3% (95% CI, 0.54-2.01). In addition, dependence on sedatives and hypnotics was found in 0.1% of screened patients, painkillers and sedatives in 0.2%, painkillers and hypnotics in 0.4% and all three substances in 0.2%. Women were slightly overrepresented. The average age was 50.3 years. Psychiatric Axis I comorbidities were diagnosed in 66.7% of all cases, mostly anxiety disorders, followed by comorbid substance use and affective disorders. CONCLUSION: The results indicate that the prevalence of DPD in general hospitals is frequent and should therefore become an important subject for health care providers. The general hospital might serve as an appropriate setting to provide early interventions for this group of patients.

Association of smoking and nicotine dependence with trauma and posttraumatic stress disorder in a general population sample.

This study is aimed at investigating the association between trauma, posttraumatic stress disorder (PTSD), smoking, and nicotine dependence. Data were collected in a representative population sample of 4075 adults aged 18 to 64 with the Composite International Diagnostic Interview. Findings show increased odds ratios (ORs) for smoking (OR: 1.28; 95% CI: 1.09-1.51) and nicotine dependence (OR: 1.52; 95% CI: 1.26-1.82) in traumatized persons, independent of PTSD. Persons with PTSD tended to have higher odds for smoking (OR: 2.12; 95% CI: 1.16-3.90) and nicotine dependence (OR: 2.70; 95% CI: 1.57-4.65), but also had lower rates for quitting smoking (OR: 0.38; 95% CI: 0.17-0.84) and for remission from nicotine dependence (OR: 0.18; CI: 0.05-0.63). We conclude that persons suffering from PTSD might need comprehensive aid in smoking cessation.

Relation among stage of change, demographic characteristics, smoking history, and nicotine dependence in an adult German population.

BACKGROUND: The aim of this study was to provide evidence about the individual intention to quit smoking and accompanying characteristics in a country with a low amount of tobacco control (TC) provisions. METHODS: This study used a random sample of the population aged 18-64 in a German area to make a quantitative estimation of the stages of change to quit smoking among current smokers who had at least one quit attempt (n = 1075). RESULTS: The rate of those who did not intend to stop smoking (precontemplators) was 76.4%, that of those who intended to quit during the next 6 months (contemplators) was 17.0%, and that of those who intended to quit during the next 4 weeks was 6.6%. The three groups did not differ according to gender or age. Of those who had at least 16 years of education, more were contemplators than were those with fewer years of education. Among those who had somatic complaints or nausea from smoking, who had their first cigarette within 1 h or less after awakening, and who had more quit attempts, more were in the contemplation or preparation stage. CONCLUSIONS: Nicotine dependence may add to contemplating about quitting. The precontemplation rate was substantially higher than in samples from nations or states which show a large amount of TC provisions.

Specific somatoform disorder in the general population.

The authors assessed the validity of the recently proposed diagnosis for specific somatoform disorder in the general population. German versions of the DSM-IV adapted Composite International Diagnostic Interview were administered to a representative sample of 4075 individuals. Multivariate analyses were used to compare impairment, life satisfaction, and use of health care. A total of 803 of 4075 subjects (19.7%) with undifferentiated somatization disorder were identified, which included 51 subjects (1.3%) who met criteria for specific somatoform disorder. Subjects with specific somatoform disorder were more impaired, had lower life satisfaction, and had higher use of health care than subjects with undifferentiated somatization disorder only. The proposed diagnosis of specific somatoform disorder demonstrated a high validity independent of comorbid depressive and anxiety disorders.