Secondary psychiatric care patients' experiences of internet CBT for insomnia - a qualitative study.

BACKGROUND: Insomnia is very common, especially among psychiatric patients in secondary care. It is experienced as a 24 h problem affecting several domains of life. Cognitive behavioural therapy for insomnia (CBT-I) is widely regarded as the first-line treatment and often improves comorbid disorders. Despite this, many patients are not offered CBT-I. Internet based CBT for insomnia (iCBT-I) is just as effective as face-to-face treatments and could considerably increase availability. However, it is unclear whether iCBT-I is suitable for patients with more severe and comorbid psychiatric illnesses in secondary care. METHODS: Eleven Swedish participants (24-68 years old) in outpatient secondary psychiatric care who underwent iCBT-I treatment were interviewed. The semi-structured interviews were analysed using content analysis. The purpose was to map their experiences, motivation and suggestions for improvement. RESULTS: Prior to the treatment, most participants were highly motivated to take the opportunity to address their insomnia. The treatment was perceived as well-structured and interesting. The most difficult aspect was counteracting the fatigue. It was also hard to continue the treatment when faced with major life events. During this phase, contact with the therapist motivated them to continue the treatment. Several desired more face-to-face meetings. It was also motivating to gain insights into and a sense of control over sleep. Several described better sleep, improved daily routines, a more predictable everyday life and increased energy. Daytime well-being was improved in some, partly because they had more energy but also because they filled their days with more activities. CONCLUSION: The treatment has the potential to be very useful in secondary psychiatric care where insomnia is common and affects comorbid disorders. Psychiatric patients might have more difficulties continuing with iCBT-I treatment, but those who manage to complete the program have a good chance of obtaining benefit. Extensive psychological groundwork early in treatment is likely to pay off later when motivation is needed. Additional social support and other adjustments may also enhance treatment outcomes. Participants' stories are particularly valuable, as therapists and treatment developers receive less feedback from patients in internet-based treatments compared to face-to-face treatments.

Two screening instruments for collecting alcohol-related information from expectant mothers and fathers: Testing the reliability of the Parent Alcohol Screening Questionnaire and the Social Support for an Alcohol-Free Pregnancy Questionnaire.

The aim is to test the reliability of two alcohol screening instruments: (1) The Parent Alcohol Screening Questionnaire (PASQ5), and (2) the Social Support for an Alcohol-free Pregnancy (SSAFP) questionnaire. This is a cohort study from the south of Sweden using repeated surveys during pregnancy. To examine if responses differed according to different data collection methods, two cohorts consisting of 289 expectant mothers and 141 fathers completed the PASQ5 both verbally (weeks 6-7) and in writing (week 12) within regular antenatal visits. One of the cohorts (n = 137/64) also completed the SSAFP in week 12 and later in week 33. The third cohort, consisting of 179 and 133 expectant mothers and fathers, respectively, completed the PASQ5 and the SSAFP twice in late pregnancy (week 31 + 33). Eight of 10 items in the PASQ5 were stable for both expectant mothers and expectant fathers when comparing verbal versus written-delivered formats. Eight of 10 questions in the PASQ5 were stable when assessing the items in a test-retest analysis in late pregnancy for expectant mothers and nine of 10 questions were stable for fathers. The SSAFP items showed high internal consistency (0.86) for expectant mothers and excellent internal consistency (0.94) for expectant fathers. Most SSAFP items (17 of 21 for expectant mothers and 18 of 22 for expectant fathers) were also stable in a test-retest scenario in late pregnancy. Both the PASQ5 and SSAFP are reliable tools and may be helpful for clinicians who aim to have a deeper dialogue about alcohol consumption during pregnancy. These tools may also be helpful for researchers aiming to better understand a person's changes in alcohol intake and/or their social support network.

Clinician experiences of healthy lifestyle promotion and perceptions of digital interventions as complementary tools for lifestyle behavior change in primary care.

BACKGROUND: Evidence-based practice for healthy lifestyle promotion in primary health care is supported internationally by national policies and guidelines but implementation in routine primary health care has been slow. Referral to digital interventions could lead to a larger proportion of patients accessing structured interventions for healthy lifestyle promotion, but such referral might have unknown implications for clinicians with patients accessing such interventions. This qualitative study aimed to explore the perceptions of clinicians in primary care on healthy lifestyle promotion with or without digital screening and intervention. METHODS: Focus group interviews were conducted at 10 primary care clinics in Sweden with clinicians from different health professions. Transcribed interviews were analyzed using content analysis, with inspiration from a phenomenological-hermeneutic method involving naïve understanding, structural analysis and comprehensive understanding. RESULTS: Two major themes captured clinicians' perceptions on healthy lifestyle promotion: 1) the need for structured professional practice and 2) deficient professional practice as a hinder for implementation. Sub-themes in theme 1 were striving towards professionalism, which for participants meant working in a standardized fashion, with replicable routines regardless of clinic, as well as being able to monitor statistics on individual patient and group levels; and embracing the future with critical optimism, meaning expecting to develop professionally but also being concerned about the consequences of integrating digital tools into primary care, particularly regarding the importance of personal interaction between patient and provider. For theme 2, sub-themes were being in an unmanageable situation, meaning not being able to do what is perceived as best for the patient due to lack of time and resources; and following one's perception, meaning working from a gut feeling, which for our participants also meant deviating from clinical routines. CONCLUSIONS: In efforts to increase evidence-based practice and lighten the burden of clinicians in primary care, decision- and policy-makers planning the introduction of digital tools for healthy lifestyle promotion will need to explicitly define their role as complements to face-to-face encounters. Our overriding hope is that this study will contribute to maintaining meaningfulness in the patient-clinician encounter, when digital tools are added to facilitate patient behavior change of unhealthy lifestyle behaviors.

Long-term effects of Internet-delivered cognitive behavioral therapy for depression in primary care - the PRIM-NET controlled trial.

OBJECTIVE: Internet-delivered cognitive behavioral therapy (ICBT) is recommended as an efficient treatment alternative for depression in primary care. However, only few previous studies have been conducted at primary care centers (PCCs). We evaluated long-term effects of ICBT treatment for depression compared to treatment as usual (TAU) in primary care settings. DESIGN: Randomized controlled trial. SETTING: Patients were enrolled at16 PCCs in south-west Sweden. PARTICIPANTS: Patients attending PCCs and diagnosed with depression (n = 90). INTERVENTIONS: Patients were assessed by a primary care psychologist/psychotherapist and randomized to ICBT or TAU. The ICBT included an ICBT program consisting of seven modules and weekly therapist e-mail or telephone support during the 3-month treatment period. MAIN OUTCOME MEASURES: Questionnaires on depressive symptoms (BDI-II), quality of life (EQ-5D) and psychological distress (GHQ-12) were administered at baseline, with follow-ups at 3, 6 and 12 months. Antidepressants and sedatives use, sick leave and PCC contacts were registered. RESULTS: Intra-individual change in depressive symptoms did not differ between the ICBT group and the TAU group during the treatment period or across the follow-up periods. At 3-month follow-up, significantly fewer patients in ICBT were on antidepressants. However, the difference leveled out at later follow-ups. There were no differences between the groups concerning psychological distress, sick leave or quality of life, except for a larger improvement in quality of life in the TAU group during the 0- to 6-month period. CONCLUSIONS: ICBT with weekly minimal therapist support in primary care can be equally effective as TAU among depressed patients also over a 12-month period. CLINICAL TRIAL REGISTRATION: The trial was registered in the Swedish Registry, researchweb.org, ID number 30511.

[Survey of early alcohol treatment preferences shows higher confidence in face to face meetings]. / Svårt att söka och få hjälp för alkoholproblem - Yrkesverksamma, socialt etablerade föredrar individuell samtalsbehandling och privat vårdgivare, visar enkätstudie.

Survey of early alcohol  treatment preferences shows higher confidence in face to face meetings Adult men and women (n = 307), working and living in the area of south west Sweden, answered a web based questionnaire where they graded treatment and caregiver preferences while imagining themselves developing an alcohol problem. Alcohol consumption was measured using AUDIT-C. Face-to-face delivered treatment was preferred over telephone or internet based advice. About 53 percent of the men and women considered treatment given by primary health as poor. Only 7,6 percent would prefer help from a health care centre if they were having alcohol problems. Shame and stigma were considered the main obstacles for both seeking and getting help. Despite the availability of effective treatments for early alcohol problems, many avoid seeking help for their problem. This also applies to socially established people. It is important that the health care recognizes and identifies people with less serious problems and offer them treatment.

Alcohol consumption among partners of pregnant women in Sweden: a cross sectional study.

BACKGROUND: Antenatal care in Sweden involves a visit in pregnancy week 6-7 for counseling about lifestyle issues, including alcohol. The aim of this study was to investigate alcohol consumption among partners of pregnant women, their motives for changing drinking patterns when becoming a parent and their perceptions of the midwife's counseling about alcohol. METHOD: The study was conducted at 30 antenatal care centers across Sweden in 2009-2010. All partners who accompanied a pregnant women in pregnancy week >17 were asked to participate. The questionnaire included questions on alcohol consumption. RESULTS: Questionnaires from 444 partners were analyzed. Most, 95 %, of the partners reported alcohol consumption before pregnancy; 18 % were binge drinking (6 standard drinks or more per occasion, each drink containing 12 grams of pure alcohol) at least once every month during the last year. More than half, 58 %, of all partners had decreased their alcohol consumption following pregnancy recognition and a higher proportion of binge drinkers decreased their consumption compared to non-frequent binge drinkers (p = 0.025). Their motives varied; the pregnancy itself, fewer social gatherings (potentially involving alcohol consumption) and a sense of responsibility for the pregnant partner were reported. Of the partners, 37 % reported support for decreased drinking from others (pregnant partner, parents, friend or workmates). Further, most partners appreciated the midwife's counseling on alcohol. CONCLUSION: A majority of partners decreased their alcohol consumption in transition to parenthood, which also appears to be a crucial time for changing alcohol-drinking patterns. The partners with higher AUDIT-C scores reported more support for decreased drinking. Most partners appreciated the midwife's talk about alcohol and pregnancy and those who filled out AUDIT in early pregnancy reported that the counseling was more engaging. During pregnancy it is possible to detect partners with high alcohol consumption, and promote interventions for decreased drinking, also for the partners. Written information addressing alcohol use and directed to partners is needed.

Impact of primary healthcare providers' initial role security and therapeutic commitment on implementing brief interventions in managing risky alcohol consumption: a cluster randomised factorial trial.

BACKGROUND: Brief interventions in primary healthcare are cost-effective in reducing drinking problems but poorly implemented in routine practice. Although evidence about implementing brief interventions is growing, knowledge is limited with regard to impact of initial role security and therapeutic commitment on brief intervention implementation. METHODS: In a cluster randomised factorial trial, 120 primary healthcare units (PHCUs) were randomised to eight groups: care as usual, training and support, financial reimbursement, and the opportunity to refer patients to an internet-based brief intervention (e-BI); paired combinations of these three strategies, and all three strategies combined. To explore the impact of initial role security and therapeutic commitment on implementing brief interventions, we performed multilevel linear regression analyses adapted to the factorial design. RESULTS: Data from 746 providers from 120 PHCUs were included in the analyses. Baseline role security and therapeutic commitment were found not to influence implementation of brief interventions. Furthermore, there were no significant interactions between these characteristics and allocated implementation groups. CONCLUSIONS: The extent to which providers changed their brief intervention delivery following experience of different implementation strategies was not determined by their initial attitudes towards alcohol problems. In future research, more attention is needed to unravel the causal relation between practitioners' attitudes, their actual behaviour and care improvement strategies to enhance implementation science. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01501552.

The Impact of an Implementation Project on Primary Care Staff Perceptions of Delivering Brief Alcohol Advice.

Objective. To explore how the perceptions and experiences of working with risky drinkers change over time among primary health care staff during a systematic implementation project. Methods. Qualitative focus group interviews took place before and after the implementation of the project. Results. The staff displayed a positive change during the implementation period with regard to awareness, knowledge, and confidence that led to a change in routine practice. Throughout the project, staff were committed to engaging with risky drinkers and appeared to have been learning-by-doing. Conclusions. The results indicated a positive attitude to alcohol prevention work but staff lack knowledge and confidence in the area. The more practical experience during the study is, the more confidence seems to have been gained. This adds new knowledge to the science of implementation studies concerning alcohol prevention measures, which have otherwise shown disappointing results, emphasizing the importance of learning in practice.

Improving the delivery of brief interventions for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial.

AIM: To test if training and support, financial reimbursement and option of referring screen-positive patients to an internet-based method of giving advice (eBI) can increase primary health-care providers' delivery of Alcohol Use Disorders Identification Test (AUDIT)-C-based screening and advice to heavy drinkers. DESIGN: Cluster randomized factorial trial with 12-week implementation and measurement period. SETTING: Primary health-care units (PHCU) in different locations throughout Catalonia, England, the Netherlands, Poland and Sweden. PARTICIPANTS: A total of 120 PHCU, 24 in each of Catalonia, England, the Netherlands, Poland and Sweden. INTERVENTIONS: PHCUs were randomized to one of eight groups: care as usual, training and support (TS), financial reimbursement (FR) and eBI; paired combinations of TS, FR and eBI, and all of FR, TS and eBI. MEASUREMENTS: The primary outcome measure was the proportion of eligible adult (age 18+ years) patients screened during a 12-week implementation period. Secondary outcome measures were proportion of screen-positive patients advised; and proportion of consulting adult patients given an intervention (screening and advice to screen-positives) during the same 12-week implementation period. FINDINGS: During a 4-week baseline measurement period, the proportion of consulting adult patients who were screened for their alcohol consumption was 0.059 per PHCU (95% CI 0.034 to 0.084). Based on the factorial design, the ratio of the logged proportion screened during the 12-week implementation period was 1.48 (95% CI = 1.13-1.95) in PHCU that received TS versus PHCU that did not receive TS; for FR, the ratio was 2.00 (95% CI = 1.56-2.56). The option of referral to eBI did not lead to a higher proportion of patients screened. The ratio for TS plus FR was 2.34 (95% CI = 1.77-3.10), and the ratio for TS plus FR plus eBI was1.68 (95% CI = 1.11-2.53). CONCLUSIONS: Providing primary health-care units with training, support and financial reimbursement for delivering Alcohol Use Disorders Identification Test-C-based screening and advice to heavy drinkers increases screening for alcohol consumption. Providing primary health-care units with the option of referring screen-positive patients to an internet-based method of giving advice does not appear to increase screening for alcohol consumption.

Professional's Attitudes Do Not Influence Screening and Brief Interventions Rates for Hazardous and Harmful Drinkers: Results from ODHIN Study.

AIMS: To determine the relation between existing levels of alcohol screening and brief intervention rates in five European jurisdictions and role security and therapeutic commitment by the participating primary healthcare professionals. METHODS: Health care professionals consisting of, 409 GPs, 282 nurses and 55 other staff including psychologists, social workers and nurse aids from 120 primary health care centres participated in a cross-sectional 4-week survey. The participants registered all screening and brief intervention activities as part of their normal routine. The participants also completed the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ), which measure role security and therapeutic commitment. RESULTS: The only significant but small relationship was found between role security and screening rate in a multilevel logistic regression analysis adjusted for occupation of the provider, number of eligible patients and the random effects of jurisdictions and primary health care units (PHCU). No significant relationship was found between role security and brief intervention rate nor between therapeutic commitment and screening rate/brief intervention rate. The proportion of patients screened varied across jurisdictions between 2 and 10%. CONCLUSION: The findings show that the studied factors (role security and therapeutic commitment) are not of great importance for alcohol screening and BI rates. Given the fact that screening and brief intervention implementation rate has not changed much in the last decade in spite of increased policy emphasis, training initiatives and more research being published, this raises a question about what else is needed to enhance implementation.

Environmental and capacity requirements are critical for implementing and sustaining a drug prevention program: a multiple case study of "Clubs against drugs".

BACKGROUND: "Clubs against drugs" (CAD) is a comprehensive program with a systems approach to prevention with the intention of preventing drug use in nightclub environment. In 2001 CAD was developed and implemented in Stockholm and was disseminated to 20 other municipalities in Sweden up until 2010. This study investigates the factors related to the implementation and compares Stockholm to the rest of the municipalities. METHODS: A sequential exploratory method was used which consisted of three steps including a questionnaire and two rounds of interviews. Questionnaires included all communities and the interviews included twelve respondents from three example municipalities in the first phase and four respondents from Stockholm in the second phase. The interviews were analyzed using content analysis. RESULTS: In Stockholm the program was described as having been implemented and sustained over time. The implementation in the example municipalities was perceived as difficult with many obstacles and achieving sustainability was also described as difficult. Two of three municipalities were not active at the time of this study, illustrating that the program only lasted a few years. Factors identified as being related to implementation outcomes were need assessments, participation, support, collaboration and local enthusiasts. CONCLUSIONS: The capacity to implement and sustain CAD differed substantially between Stockholm and the other municipalities. If the prerequisites and capacity are not sufficient the implementation is not likely to be successful, even when the activities are promoted on a national level like CAD. The needs of the interventions and the capacity to implement the program should be examined before adopting the program. This was not done, probably because the drive to spread the activity was not sufficiently questioned.

Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial.

BACKGROUND: The European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers. METHODS/DESIGN: In a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals' role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling. DISCUSSION: Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.

Comparison of systematic versus targeted screening for detection of risky drinking in primary care.

AIM: To compare two identification methods for risky drinking in primary health care centres (PHCs). METHODS: Sixteen PHCs from three Swedish counties were randomized into strands: consultation-based early identification (CEI) or systematic screening early identification (SS). Measurements took place at baseline and during two intervention periods. Patients filled in questionnaires including gender, age, if they had the issue of alcohol brought up during the consultation and the AUDIT-C (a three item screening tool). The intervention periods were preceded by training sessions for clinicians. The AUDIT-C was used for categorization of risky drinking with cut-offs for risky drinking set at ≥5 for men and ≥4 for women. In the SS strand, clinicians were supposed to give AUDIT-C to all patients for the identification of risky drinking. In the CEI strands, they were encouraged to use early clinical signs to identify risky drinking. RESULTS: The proportions of patients having the issue of alcohol brought up are higher during the intervention periods than baseline. A higher proportion of all patients and of risk drinkers in SS, than in CEI, had the issue of alcohol brought up. A higher mean score of AUDIT-C was found among patients having the issue of alcohol brought up in CEI than in SS, and this was also true after adjusting for age and gender. CONCLUSIONS: More patients are asked about alcohol in the SS strand and thus have the possibility of receiving brief interventions. CEI identifies risk drinkers with higher AUDIT-C scores which might indicate more severe problems. No comparison of the effectiveness of a brief intervention following these alternative identification procedures is reported here.

Women's patterns of everyday occupations and alcohol consumption.

Earlier studies on women's health and drinking and the contemporary associated risk factors have highlighted the need for more complex approaches in understanding the pathways into women's problem drinking. Research, from both social science and from occupational therapy models, has underlined the importance of deconstructing the often dichotomized way of investigating women's daily lives (such as in paid and unpaid work or in work and leisure) when discussing factors from the daily life environment and their impact on health issues. The aim of this study was to explore the relationship between women's patterns of everyday occupation and alcohol consumption using the broader concept of occupation from occupational therapy models. This was a cross-sectional study from the latest wave (2000) of a population-based project, Women and Alcohol in Gothenburg (WAG). The study group consisted of 851 women, aged 20-55 years. Using an individually oriented method, two-step clustering, three distinct patterns of everyday occupations were identified. Significant associations with problematic alcohol consumption were found in the clusters, characterized by lower engagement in leisure activities and a larger amount of spare time. The need for new preventive approaches, including investigating the importance of having engaging leisure activities, is discussed.

Substance use/abuse and suicidal behavior in young adult women: a population-based study.

Associations between substance use variables and suicidal behavior were analyzed in an urban population sample from ("the Women and Alcohol in Gothenburg" study). In Phase I, 20-year-old women (n = 2,069) completed a screening questionnaire. Interviews were carried out with a stratified sample (n = 560). Data, collected in 1995 and 2000, were analyzed using logistic regression to generate odds ratios. Drug use, but not risky alcohol consumption, was associated with suicidal thoughts after adjusting for current depression. Study limitations and implications for suicide prevention are discussed. The study was funded by the Swedish Research Council and the Alcohol Research Council of Sweden.

Different methods of early identification of risky drinking: a review of clinical signs.

AIMS: To review the literature on detection of risky drinking to compare early identification based on everyday clinical encounters with systematic screening. We also reviewed specific clinical signs that have been suggested to be used as indicators of risky drinking. METHODS: A literature review was performed in PubMed and CINAHL of articles up to November 2010. RESULTS: Systematic screening and semi-systematic methods in various forms detected more risky drinkers than non-systematic identification during clinical encounter, but there was a lack of studies comparing the various means of identifying risky drinking. It may be too early to completely rule out the possibility of using non-systematic methods as an effective strategy to identify risky drinking. The earliest signs of risky drinking suggested in the literature are psychological distress and social problems. CONCLUSION: From a public health perspective, there is a lack of evidence that non-systematic or semi-systematic methods can substitute systematic screening in terms of numbers of risky drinkers detected. If early signs are going to be used to identify risky drinkers, or those to be screened for risky drinking, more focus should be on psychological and social signs because they appear earlier than somatic signs.

Does gender matter? A vignette study of general practitioners' management skills in handling patients with alcohol-related problems.

AIMS: The aims of this study were to analyse the perceptions of female and male primary care physicians (PCPs) of alcohol problems in male and female patients, their recommendations to reduce or abstain from alcohol, their referrals to treatment and their views of safe levels of drinking for male and female patients. These factors were related to the physicians' own alcohol consumption. METHODS: A slightly adjusted version of the WHO Collaborative Study Questionnaire for General Practitioners was posted to all PCPs (n = 132) in the district of Skaraborg, Sweden, of whom 68 PCPs responded. In the questionnaire, the PCPs' perceptions of two patient vignettes were analysed. RESULTS: Both the gender of the patients in the vignettes and of the PCPs influenced the advice and the referrals that the patients received: 83% of male excessive drinkers and 47% of female excessive drinkers were recommended to cut down on drinking. In 50% of cases, the male excessive drinker was not referred, compared with 25% for the female excessive drinker. This was statistically significant only for excessive drinkers. The odds ratio for referral to any treatment was 0.33 (CI = 0.12-0.93) for the male excessive drinker compared with the female excessive drinker. The male PCP referred the excessive drinker less often to any treatment than did the female PCP, odds ratio 0.26 (CI = 0.08-0.90). The upper limit of alcohol consumption before the PCPs would advise the patient to cut down was significantly higher for PCPs with the AUDIT-C score >or= 3. The limit was 146 g/week for male patients and 103 g/week for female patients. Corresponding figures for PCP with the AUDIT-C score

Lack of leadership confidence relates to problem drinking in women: gender identity, heavy episodic drinking and alcohol use disorders in Swedish women.

AIM: The aim of this study was to analyse in women the association between four dimensions of gender identity, heavy episodic drinking (HED) and alcohol use disorders (AUD), taking into account age, personality, psychiatric co-morbidity and level of education. METHODS: An initial screening of alcohol consumption was followed by a structured psychiatric interview in a sample of women drawn from the Gothenburg population and women attending primary care, maternity and hospital services (n = 930). Gender identity was assessed using the Masculinity-Femininity Questionnaire (M/F-Q) (items grouped into four dimensions: leadership, caring, self-assertiveness and emotionality). The Karolinska Scale of Personality was administered. Clinical psychiatric diagnoses according to DSM were made in face-to-face interviews. HED was defined as consumption of at least 60 g of ethanol on a single day at least once a month. RESULTS: Women who scored low on the leadership dimension were twice as likely to have AUD [age-adjusted odds1.98 (95% confidence interval 1.30-3.01)] compared to those with medium scores. These odds ratios were significant after adjustment for personality [2.21 (1.35-3.63)], psychiatric disorders [2.09 (1.25-3.47)] and level of education [1.95 (1.17-3.26)]. Low scores on the leadership dimension were associated with HED [1.55 (0.98-2.44)] after adjustment for age, personality, psychiatric disorders and level of education. High scores on leadership were not significantly associated with AUD or HED after these adjustments. The odds ratios for those who scored low on caring were non-significant throughout the analyses of associations with both AUD and HED. A similar pattern was found for the self-assertiveness dimension. Low emotionality was associated with decreased odds for AUD [0.42 (0.25-0.70)] and HED [0.66 (0.44-0.99)], and increased odds for AUD [2.14 (1.38-3.31)] and HED [2.33 (1.58-3.44)], after adjusting for age. These associations became non-significant after adjustment for personality and remained so after psychiatric disorders and level of education were added to the models. CONCLUSION: Of the four gender identity dimensions, only low scores on leadership remained significantly associated with AUD and HED after adjustment for age and personality. Clinical work could focus on the development of leadership abilities in women scoring low on these items to improve the ability.