["Epidemiology of mental disorders and access to mental health care. EZOP - Poland" - research methodology]. / "Epidemiologia zaburzen psychiatrycznych i dostepnosc psychiatrycznej opieki zdrowotnej. EZOP - Polska" - metodologia badania.

AIM: Since the second half of the twentieth century, with the development of structured diagnostic tools, population based studies on epidemiology of mental disorders are carried out. A special role is played by World Mental Health Survey Initiative which brings together a group of countries from different continents in order to carry out research projects according to standard methodology using the Composite International Diagnostic Interview. Polish EZOP study, which was conducted in accordance with the guidelines of WMH joined that group. The project was implemented under the Norwegian Financial Mechanism and the Financial Mechanism of the European Economic Area. Its aim was to estimate the prevalence of mental disorders in the Polish population of adults, assess the distance to mental disorders and to obtain knowledge about the perception of psychiatric disorders and treatment. METHODS: The research tool was the Polish version of CIDI-WHO ver.3.0., which was developed for the project. The study was performed in accordance with the guidelines of WMH (cognitive interviews, interviewers training, standardization of field procedures) using electronic version of CIDI questionnaire (CAPI) within the 2-stages procedure in randomly selected representative sample of the Polish population aged 18-64. The quality of the study was systematically controlled and reported by MB SMG/KRC, and completed data (10,081 interviews) were sent to the Department-Centre of Monitoring and Analyses of Population Health NIPH-NIH. After the initial analysis data were sent to the analytical center of WMH, which applied additional cleaning tools and added new variables representing psychiatric diagnoses in DSM-IV and ICD-10.

What influences changes in alcoholic beverage consumption over time? Poland in the light of the European Union Amphora study.

This paper is based on the Polish country-level final report of the European Union Amphora study: contextual determinants and alcohol polices. The authors present the results of a time series analysis model designed to explore and explain the influence of selected alcoholic beverage control policy measures and unplanned sociodemographical determinants on changes in alcoholic beverage consumption from 1960 to the 2000s in Poland. Complex historical and social changes are described, which occurred during the 50 years covered by the study. The study findings confirmed that sociodemographical determinants have an important influence on alcoholic beverage consumption. Study limitations are noted and future research is suggested.

Alcohol as a trigger for medical emergencies.

In this paper, our goal is to report relative risks of the impact of alcohol consumption 6 hours prior to medical emergencies presenting in the emergency department for 8,346 patients in seven countries using data from the Emergency Room Collaborative Alcohol Analysis Project. We found that alcohol increased the risk of a medical emergency by 2.17 times (confidence interval: 1.78-2.65), and those without a regular pattern of heavy drinking and those younger showed a greater risk. Acute alcohol is associated not only with injury but also with medical emergencies. More studies are needed on the acute role of alcohol in medical emergencies, preferably with data on the type of medical emergencies.

Threshold and optimal cut-points for alcohol use disorders among patients in the emergency department.

BACKGROUND: Current research suggests that Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV alcohol abuse and dependence form a unidimensional continuum in emergency department (ED) patients in 4 countries: Argentina, Mexico, Poland, and the United States. In this continuum of alcohol use disorder (AUD), there are no clear-cut distinctions between the criteria for dependence and abuse in the severity dimension based on prior results from item response theory (IRT) analysis. Nevertheless, it is desirable to find a threshold for identifying cases for clinical practice and cut-points of clinical utility in this continuum to distinguish between patients more or less affected by an AUD, using a scale of symptoms count. METHODS: Data from 5,193 patients in 7 ED sites in the same 4 countries (3,191 current drinkers) were used to study the structure, threshold, and possible cut-points for the diagnoses of AUD. RESULTS: The proposed changes in the DSM-V, dropping the abuse item "legal problems" and adding an item on "craving," did not impact the IRT performance and unidimensionality of AUD in this sample. With a total set of 11 items (deleting "legal problems" and adding "craving" to the current set of DSM criteria), an endorsement of 2 or more criteria can be used as the threshold to define those with an AUD in clinical practice. Furthermore, we can distinguish at least 2 levels of clinical severity, 2 to 3 criteria (moderate), and 4 or more criteria (severe). CONCLUSIONS: A dimensional approach to AUD using the proposed new set of criteria for the DSM-V can be used to propose a threshold and levels of severity. More research in different populations and countries is needed to further substantiate a threshold and cut-points that could be used in new formulations of substance use disorders.

Contextual determinants of alcohol consumption changes and preventive alcohol policies: a 12-country European study in progress.

Beginning with France in the 1950s, alcohol consumption has decreased in Southern European countries with few or no preventive alcohol policy measures being implemented, while alcohol consumption has been increasing in Northern European countries where historically more restrictive alcohol control policies were in place, even though more recently they were loosened. At the same time, Central and Eastern Europe have shown an intermediate behavior. We propose that country-specific changes in alcohol consumption between 1960 and 2008 are explained by a combination of a number of factors: (1) preventive alcohol policies and (2) social, cultural, economic, and demographic determinants. This article describes the methodology of a research study designed to understand the complex interactions that have occurred throughout Europe over the past five decades. These include changes in alcohol consumption, drinking patterns and alcohol-related harm, and the actual determinants of such changes.

Screening, brief intervention, and referral to treatment (SBIRT): 12-month outcomes of a randomized controlled clinical trial in a Polish emergency department.

BACKGROUND: A randomized controlled trial of screening, brief intervention, and referral to treatment (SBIRT) among at-risk (based on average number of drinks per week and drinks per drinking day) and dependent drinkers was conducted in an emergency department (ED) among 446 patients 18 and older in Sosnowiec, Poland. METHODS: Patients were recruited over a 23-week period (4:00 pm to 12:00 midnight) and randomized to 1 of 3 conditions: screened-only (n = 147), assessed (n = 152), and intervention (n = 147). Patients in the assessed and intervention conditions were blindly reassessed via a telephone interview at 3 months, and all 3 groups were assessed at 12 months (screened-only = 92, assessed = 99, and intervention = 87). RESULTS: No difference was found across the 3 conditions in at-risk drinking at 12 months, as the primary outcome variable, or in decrease in the number of drinks per drinking day, with all 3 groups showing a significant reduction in both. Significant declines between baseline and 12 months in secondary outcomes of the RAPS4, number of drinking days per week, and the maximum number of drinks on an occasion were seen only for the intervention condition, and in negative consequences for both the assessment and intervention conditions. CONCLUSIONS: Data suggest that improvements in drinking outcomes found in the assessment condition were not because of assessment reactivity, with both the screened and intervention conditions demonstrating greater (although nonsignificant) improvement than the assessed condition. Only those in the intervention condition showed significant improvement in all outcome variables from baseline to 12-month follow-up. Although group by time interaction effects were not found to be significant, these findings suggest that declines in drinking measures for those receiving a brief intervention can be maintained at long-term follow-up.

[Psychiatric epidemiology--recent advances]. / Epidemiologia zaburzen psychicznych--dotychczasowe doswiadczenia.

The aim of this article is to review recent advances and the latest research trends in psychiatric epidemiology. Examination of mental disorders prevalence delivers important information about the mental state of society and need for professional psychiatric care. The 12 months prevalence estimates are 30% for any mental disorders. Knowledge about historical methods of data collecting helps to understand psychiatric epidemiology better. We overview few generations of research that differ in methodology. The most common difficulties observed during that kind of research will be described. Available methods of examination of mental disorders prevalence will be presented in this article. The most significant results of international WHO epidemiologic project will be discussed. We also point out future challenges for psychiatric epidemiology and predict the systemic solutions that make intercultural comparisons possible.

Acute alcohol use and the risk of non-fatal injury in sixteen countries.

AIMS: To determine the relative risk (RR) of non-fatal injury associated with alcohol consumption in a series of emergency departments (EDs), possible effect modifiers and the impact of contextual variables on differences across sites. DESIGN: The case-crossover method was used to obtain RR estimates of the effect of alcohol on non-fatal injuries. Meta-analysis was used to evaluate the consistency and magnitude of RR across sites, and the extent to which contextual variables explain differences in effect sizes. PARTICIPANTS: Probability samples of 11,536 injured patients attending 28 EDs studies in 16 countries (1984-2002). The majority of the sample was male (65%) and > 30 years old (53%). MEASUREMENTS: Exposed cases where those that consumed alcohol 6 hours prior to the injury. Usual alcohol consumption served as the control period. FINDINGS: Drinking within 6 hours prior to the injury was reported by 21% of the sample. The estimated (random) pooled relative risk for patients who reported alcohol use within 6 hours prior to injury was 5.69 (95% confidence interval = 4.04-8.00), ranging from 1.05 in Canada to 35.00 in South Africa. Effect size was not homogeneous across studies, as societies with riskier consumption patterns had a higher relative risk for injury. Heavier drinkers also showed lower RR. CONCLUSIONS: Acute alcohol was a risk factor for non-fatal injuries in most sites. Policy measures addressed to the general population are recommended, especially in societies with riskier consumption patterns.

The effect of alcohol consumption on emergency department services use among injured patients: A cross-national emergency room study.

OBJECTIVE: Although injured patients in the emergency department (ED) report more frequent use of the ED compared with the general population, and alcohol-related admissions and chronic alcohol misuse have been found to be predictive of future ED admissions, these data are based on only a few U.S. studies. The purpose of this article was to explore the association of alcohol use and ED services use among injured patients cross-nationally. METHOD: Binary and multinomial logistic regression were used to analyze the association of alcohol consumption with prior ED visits among 9,743 injured patients surveyed in 37 EDs in 14 countries and reported in 23 studies from the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and World Health Organization Collaborative Study of Alcohol and Injuries. RESULTS: Drinking within 6 hours before injury was associated with prior ED visits during the last 12 months (odds ratio = 1.25, p < .05), with a positive dose-response relationship. Heavy drinkers and those drinkers who were alcohol-dependent were also significantly more likely to report multiple prior ED visits, reflecting an elevated burden of services use. At the ED level, stigmatization of alcohol use was the only significant contextual variable that consistently predicted cross-ED variation in the relationship between drinking and ED use, in which the association was weaker in areas where alcohol use is less accepted. CONCLUSIONS: This study lends additional support to the potential effectiveness of screening for acute and chronic alcohol use among ED injured patients to reduce ED services use and associated costs.

Screening for alcohol problems in two emergency service samples in Poland: comparison of the RAPS4, CAGE and AUDIT.

Prior research on alcohol-related problems among emergency service patients in Poland found substantial alcohol involvement on the part of injured males, suggesting emergency services may be a productive venue for identifying patients who could benefit from a brief intervention or referral for treatment. Performance of the RAPS4, CAGE and AUDIT against ICD-10 and DSM-IV criteria for alcohol dependence and for alcohol abuse/harmful drinking was compared in probability samples of emergency service patients from two regions of Poland. Sensitivity of the RAPS4 and AUDIT was significantly better than the CAGE for alcohol dependence among males in Warsaw, but specificity was poorer. Among females, although numbers were small, sensitivity for alcohol abuse/harmful drinking and for alcohol dependence or abuse/harmful drinking was significantly better for the RAPS4-QF than for the CAGE or AUDIT at a cut point of 8 across both sites. Performance of the AUDIT at a cut point of 3 was similar to the RAPS4-QF for females. Among males, sensitivity was higher but specificity considerably lower for the RAPS4-QF compared to the CAGE at a cut point of 1 or for the AUDIT at a cut point of 8. Alternate cut points for the AUDIT optimized performance. Findings suggest some regional and gender differences in performance of screening instruments in these Polish samples, but no instrument or cut point is optimal in identifying those with alcohol use disorders. Additional cross-cultural research is needed to evaluate the performance of instruments, especially among females with alcohol use disorders.

Cross-national performance of the RAPS4/RAPS4-QF for tolerance and heavy drinking: data from 13 countries.

OBJECTIVE: There are little data available on the performance of brief screening instruments for alcohol-use disorders cross-nationally; therefore, we analyzed the performance of one such instrument in a number of countries. METHOD: Performance of the RAPS4 for tolerance and the RAPS4-QF for heavy drinking are analyzed from emergency room data across 13 countries included in the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the World Health Organization Collaborative Study on Alcohol and Injuries. RESULTS: The RAPS4 showed good sensitivity and specificity for tolerance across most of the countries, but was higher in countries that were higher on societal-level detrimental drinking patterns. Prevalence of tolerance was also higher in those countries with high detrimental drinking pattern scores. Sensitivity of the RAPS4-QF for heavy drinking was uniformly high across countries, while maintaining good specificity, and did not vary by detrimental drinking patterns. CONCLUSIONS: Findings suggest the RAPS4 and RAPS4-QF may hold promise cross-nationally. Future research should more fully address the performance of brief screening instruments for alcohol-use disorders (using standard diagnostic criteria) cross-nationally, with consideration of the impact of societal drinking patterns.

Does Brief Intervention Work For Heavy Episodic Drinking? A Comparison of Emergency Department Patients in Two Cultures.

Little has been reported on the efficacy of brief intervention (BI) among heavy episodic drinkers, although this drinking style is known to be especially harmful in relation to negative consequences including alcohol-related injuries. The comparative efficacy of BI is analyzed in two similar randomized controlled clinical trials of emergency department (ED) patients in two different cultures, both of which exhibit similar drinking styles of heavy episodic drinking: Poland and Mexican-Americans in the U.S. Improvements in drinking and problem outcomes are analyzed at 3-month and 12-month follow-up, using random effects modeling, among 446 Polish patients and 698 Mexican-American patients, randomized to screened only, assessment, and intervention conditions in each study. In Poland significant improvement was observed in all outcome measures for the assessed condition at 3-months compared to baseline, but only in the two problem variables at 12-months, while for the intervention condition, significant improvement was found in all outcome measures at both time periods; however, estimates of the interaction terms were not statistically significant. In the Mexica-American study, while significant improvement in nearly all outcome measures were observed at 3 months and 12 months for both conditions, estimates of the interaction terms suggest that for all drinking variables, but not problem variables, outcomes were significantly improved for the intervention condition over the assessed condition at 12 months, suggesting a 12-month intervention effect. Findings here are non-conclusive regarding a treatment effect of BI for heavy episodic drinking in ED patients. Given the mixed findings for BI in other ED studies, future studies need to explore the efficacy of BI in other populations and cultures exhibiting different drinking patterns to help identify what type of drinker would most benefit from BI in the ED setting.

Comparison of different methods assessing alcohol contribution to emergency room visits.

INTRODUCTION: The main objective of research was to compare different methods of assessing alcohol's contribution to injuries and medical conditions treated in ER in Poland. Four methods are discussed, including breathalyzer reading, clinical appraisal following Y91 codes of ICD 10, interviewer's observation and self-report. METHODS: In two Polish sites Warsaw and Sosnowiec probability samples of patients admitted to ER were selected and interviewed face-to-face by trained interviewers. Almost 1.5 thousand patients were interviewed with response rate of 67%. To identify injuries and medical conditions associated with drinking (preceded by alcohol consumption) four methods were used: clinical observations made by nurses trained in applying Y91 codes of ICD-10 (in the Sosnowiec ER only), observations by interviewers who did not receive such a training, breathalyzer readings and patient self-reports of drinking within six hours prior to the event. RESULTS: A breathalyzer reading identified 4.5% under the influence of alcohol among all patients, and 5.7% among those who were breathalyzed. Clinical assessment in Sosnowiec and interviewers' observations in both cites identified almost the same proportion: 5.1% and 4.7%, respectively and self-reports almost 10%. All four measures for identifying potentially alcohol related ER visits found a total of 11.5% cases among sampled patients.

Readiness to change, drinking, and negative consequences among Polish SBIRT patients.

The aim of this study is to examine the longitudinal relationship of readiness to change, drinking pattern, amount of alcohol consumed, and alcohol-related negative consequences among at-risk and dependent drinkers enrolled in a Screening, Brief Intervention and Referral to Treatment (SBIRT) trial in an emergency department in southern Poland. The study examined 299 patients randomized to either an assessment or intervention condition and followed at 3 and 12 months after initial presentation. Patients indicating a readiness or were unsure of changing drinking behavior were significantly more likely to decrease the maximum number of drinks per occasion and the usual number of drinks in a sitting in the 3-months following study entry when compared to those that rated changing drinking behavior as unimportant. Readiness to change was not predictive of outcomes between the baseline and 12-month follow-up. Drinking outcomes and negative consequences by readiness and research condition were non-significant. This is the first Polish study utilizing SBIRT to enable patients to identify their hazardous drinking and reduce alcohol consumption. While some drinking outcomes improved with motivation, these improvements were not maintained at 12-months following SBIRT. Attention to additional constructs of readiness to change and drinking patterns may augment the effectiveness of SBIRT.

Scaling properties of the combined ICD-10 dependence and harms criteria and comparisons with DSM-5 alcohol use disorder criteria among patients in the emergency department.

OBJECTIVE: The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), and the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), alcohol use disorders (AUDs) classifications offer competing and somewhat overlapping diagnostic tools for assessing alcohol dependence and harms/abuse. Both systems are in active stages of development in anticipation of their next respective iterations. Although much psychometric work has been done studying DSM-IV criteria, efforts toward the ICD-11 have been less prevalent. METHOD: Data from 3,191 drinkers in seven emergency department sites in four countries (United States, Mexico, Argentina, and Poland) were used to study the psychometric properties of the combined ICD-10 dependence and harms criteria. Comparisons with the proposed set of DSM-5 criteria and diagnostic thresholds are also included. RESULTS: Item response theory analyses of the combined ICD-10 dependence and harms criteria suggested a single underlying factor, both overall and for each site separately, with only moderate differential item functioning across sites. Overall agreement between the summative combined ICD-10 dependence and harms criteria and the proposed 11-criteria DSM-5 scale was very high (r = .97), as was agreement between proposed diagnostic threshold levels of 0-1 (negative AUD), 2-3 (moderate AUD), and 4 or more (severe AUD) criteria endorsed (κ = .84). Although disagreement between the two three-level diagnoses was only 5.5% of the sample, a majority of these were because of differences between endorsement rates of abuse versus harms criteria. CONCLUSIONS: Although there is support for efforts to align the two schemes, results are consistent with other studies finding the largest differences between the two systems emanating from differences between the abuse and harms domains. More research is needed before differences between the two systems can be reconciled.

The dimensionality of alcohol use disorders and alcohol consumption in a cross-national perspective.

AIMS: To replicate the finding that there is a single dimension trait in alcohol use disorders and to test whether the usual 5+ drinks for men and 4+ drinks for women and other measures of alcohol consumption help to improve alcohol use disorder criteria in a series of diverse patients from emergency departments (EDs) in four countries. DESIGN: Cross-sectional surveys of patients aged 18 years and older that reflected consecutive arrival at the ED. The Composite International Diagnostic Interview Core was used to obtain a diagnosis of DSM-IV alcohol dependence and alcohol abuse; quantity and frequency of drinking and drunkenness as well as usual number of drinks consumed during the last year. SETTING: Participants were 5195 injured and non-injured patients attending seven EDs in four countries: Argentina, Mexico, Poland and the United States (between 1995-2001). FINDINGS: Using exploratory factor analyses alcohol use disorders can be described as a single, unidimensional continuum without any clear-cut distinction between the criteria for dependence and abuse in all sites. RESULTS: from item response theory analyses showed that the current DSM-IV criteria tap people in the middle-upper end of the alcohol use disorder continuum. Alcohol consumption (amount and frequency of use) can be used in all EDs with the current DSM-IV diagnostic criteria to help tap the middle-lower part of this continuum. Even though some specific diagnostic criteria and some alcohol consumption variables showed differential item function across sites, test response curves were invariant for ED sites and their inclusion would not impact the final (total) performance of the diagnostic system. CONCLUSIONS: DSM-IV abuse and dependence form a unidimensional continuum in ED patients regardless of country of survey. Alcohol consumption variables, if added, would help to tap patients with more moderate severity. The DSM diagnostic system for alcohol use disorders showed invariance and performed extremely well in these samples.

Performance of a craving criterion in DSM alcohol use disorders.

OBJECTIVE: Adding a craving criterion--presently in the International Classification of Diseases, 10th Revision, diagnosis of alcohol dependence--has been under consideration as one possible improvement to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and was recently proposed for inclusion by the DSM Substance-Related Disorders Work Group in the Fifth Revision of diagnostic criteria for alcohol use disorders. To inform cross-cultural applicability of this modification, performance of a craving criterion was examined in emergency departments in four countries manifesting distinctly different culturally based drinking patterns (Mexico, Poland, Argentina, United States). METHOD: Exploratory factor analysis and item response theory were used to examine psychometric properties and individual item characteristics of the 11 DSM-IV abuse and dependence criteria with and without craving for each country separately. Differential item functioning analysis was performed to examine differences in the difficulty of endorsement (severity) and discrimination of craving across countries. RESULTS: Exploratory factor analysis found craving fit well within a one-dimensional solution, and factor loadings were high across all countries. Results from item-response theory analyses indicated that both discrimination and difficulty estimates for the craving item were located in the middle of the corresponding discrimination and difficulty ranges for the other 11 items for each country but did not substantially increase the efficiency (or information) of the overall diagnostic scheme. Across the four countries, no differential item functioning was found for difficulty, but significant differential item functioning was found for discrimination (similar to other DSM-IV criteria). CONCLUSIONS: Findings suggest that, although craving performed similarly across emergency departments in the four countries, it does not add much in identification of individuals with alcohol use disorders.

Screening, brief intervention, and referral to treatment (SBIRT) in a Polish emergency department: three-month outcomes of a randomized, controlled clinical trial.

OBJECTIVE: A randomized, controlled trial of screening, brief intervention, and referral to treatment (SBIRT) for drinking and related problems among at-risk and dependent drinkers was conducted in an emergency department (ED) in Sosnowiec, Poland, among patients ages 18 years and older. METHOD: Data were collected over a 23-week period, from 4:00 PM to midnight, and resulted in 446 patients being recruited into the study (90% of those who screened positive) and randomized to three conditions following a two-stage process: screened only (n = 147), assessed (n = 152), and received intervention (n = 147). Patients in the assessment (85%) and intervention (83%) conditions were blindly reassessed at 3 months via a telephone interview. RESULTS: At 3-month follow-up, both groups showed significant decreases in the proportion who were positive for at-risk drinking, the primary outcome variable. Both groups also showed significant decreases in drinking days per week, drinks per drinking day, maximum drinks per occasion, and negative consequences of drinking. Using analysis of covariance to control for baseline measures and demographic characteristics, no difference in outcome measures was found between intervention and assessment conditions. Subgroup analysis found some significant interactions between intervention and secondary outcomes. CONCLUSIONS: Although the main findings were similar to those from other brief-intervention studies in Western cultures, findings here also suggest that intervention may have differential benefits for specific subgroups of patients in the ED, an area of research that may warrant additional study of brief intervention in the ED setting.

SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT (SBIRT) IN A POLISH EMERGENCY ROOM: CHALLENGES IN CULTURAL TRANSLATION OF SBIRT.

A randomized clinical controlled trial of screening, brief intervention and referral to treatment (SBIRT) for drinking and related problems among at-risk and dependent drinkers, using nurse interventionists, was undertaken in an emergency room (ER) in Sosnowiec, Poland, the first level-one trauma center in that country. This study was the first outside of the U.S. to test protocols developed in a 14-site collaborative SBIRT study. Because Poland has both a pattern of heavy drinking and a highly accessible specialized alcohol treatment system, it offered a key setting for cultural translation of SBIRT to the international context of a new and emerging health care system. It also offered the opportunity to test the effectiveness of SBIRT with both at-risk and dependent drinkers, and to test the feasibility of using ER nursing staff to provide the brief intervention, serving as a potential model for ongoing implementation of SBIRT in ER settings. Findings suggest that the U.S.-based SBIRT protocols can be successfully translated to other cultures, and that nurses can be successfully trained to provide brief intervention for problem drinking in the ER setting.