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Keywords:

  • alcoholism;
  • mortality;
  • self-help groups;
  • social support;
  • survival analysis

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Abstract  The present study aimed to determine whether alcoholics who attend self-help groups experience fewer deaths than those who do not. Subjects were patients from the Alcoholism Treatment Program (ATP) of Matsuzawa hospital. A cohort of alcoholic patients recruited into a prospective study was followed from April 1994 to March 1999. A total of 469 alcoholic patients met the International Classification of Diseases (10th edition) criteria for alcohol dependency. Of these, 94 patients refused to participate in the study, leaving a total of 375 participants. After discharge from the ATP and a complete explanation of the present study, subjects decided whether to attend a self-help group (SHG) or not. The SHG comprised 208 subjects, and the non-self-help group (NSHG) comprised 167 subjects. Outcomes were evaluated with regard to death during follow-up for a mean of 2.4 years. Death was ascertained through the records of the Setagaya Department of Health and Welfare center, Matsuzawa hospital and other hospitals, and through personal contact with informants, relatives, and significant others of subjects. Deaths were confirmed for 47 NSHG subjects and only five SHG subjects. NSHG displayed a significantly decreased cumulative survival compared with SHG (P < 0.0001). Cox proportion hazard analysis was used to examine variables that may help to predict mortality among alcoholics. Alcoholics who attended self-help groups differed from those who did not, with regard to mortality experience. Attending a self-help group represented the most important predictor of prognosis for alcoholics.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Alcoholism is associated with increased mortality,1 and cross-cultural data indicate that alcoholic patients display mortality rates two to sixfold higher than average males.2 This high mortality stems from all major diseases, accidents, violence, and suicide.3,4

While most studies have focused on proximal causes of excess death among alcoholics rather than on specific contributing risk factors, some reports have attempted to identify possible predictors. Age and socioeconomic status have been associated with increased risk of mortality among alcoholics,5–7 as have pre-existing and coincident physical illness, patterns of ethanol consumption,3 psychiatric status,8,9–11 and neuropsychological condition.3,4 However, consensus regarding which predictors of mortality are most associated with alcoholism has not been achieved.

We have assumed that the most important predictor of mortality among alcoholics is attendance of a self-help group (SHG). To examine this hypothesis, we selected alcoholics who had been discharged from Tokyo Metropolitan Matsuzawa hospital after undergoing the Alcoholism Treatment Program (ATP).

SUBJECTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Subjects

During the period from 1994 to 1997, a total of 469 alcoholic patients were discharged from the ATP at Matsuzawa hospital. Before admission to the ATP, all 469 met the International Classification of Diseases, 10th edition (ICD-10) criteria for alcoholism.12 Patients had been admitted to the ATP for weaning (mean duration, 2 weeks) following at least one outpatient consultation. The usual duration of the ATP is 3 months. After admission, patients received physical examinations (blood, urine, electrocardiography, chest radiography, brain computed tomography, and electroencephalography if necessary) and were given treatment if in poor health. Alcoholic withdrawal began on admission and was associated with rest, adequate fluid intake, and treatment with sedatives. In the first week of withdrawal, the clinical, psychological and social status of patients was assessed. Afterwards, individual and group psychotherapy, videotapes, occupational therapy, and gymnastics were widely used. When making a discharge schedule in the way of the ATP, we asked their approval for our study plane, and 94 patients expressed their will not to participant in our projects. However, 375 patients did choose to participant. When making a discharge schedule soon after completing the ATP, the patients determined whether to attend a SHG after a complete explanation of our project. Informed consent was obtained in accordance with the policies of the ethics committee of Matsuzawa hospital.

Study design

When these 375 alcoholic patients were discharged, the purposes of the study were explained and each patient determined whether to attend a SHG. Up until 31 March 1997, subjects were categorized into two groups; SHG (n = 208) or non-self-help group (NSHG; n = 167). The SHG subjects attended Alcoholic's Anonymous regularly.

Follow-up was performed from 1 April 1994 to 31 March 1999. Mean length of observation (total time the patient was involved in the study) was 2.34 ± 1.36 years. Subjects entered the study at various times throughout the 3-year period between April 1994 and March 1997.

Following agreement to participate, subjects were scheduled for an evaluation of interviews with a psychiatrist, health center staff, clinical counselor, and welfare center caseworker. The design of the study called for periodic re-evaluation to include monitoring of mortality status (alive vs. dead). Based on ICD-10 classifications, causes of death were classified into three groups: death due to disease and natural causes; death due to disaster; and death due to other or unknown causes.

To supplement our own mortality data, additional information was obtained from the records of the Setagaya Department of Health and Welfare center (n = 37). We obtained other mortality information on these subjects through Matsuzawa hospital (n = 10), other hospitals and clinics attended (n = 3), and phone and/or written communications with relatives or their friends (n = 2).

Variables

Table 1 presents demographic and descriptive data for the two groups at the time of enrollment. Subjects comprised 321 males and 54 females. Mean age at enrollment was 48.8 ± 11.3 years. Significant differences in family and occupational status were observed between the two groups.

Table 1. Relative characteristic at enrollment of self-help group and non-self-help group
 SHGNSHGχ2P
  1. SHG, Self-help group; NSHG, Non-self-help group; NS, Not significant.

Age (years)
 21–39 47 36  
 40–59127 96 1.315NS
 60 34 35  
 Mean48.6 ± 11.149.0 ± 11.6  
Sex
 Male178143 2.018NS
 Female 30 24
Physical illness
 Present 49 47 1.023NS
 Absent159120
Health insurance
 On welfare 73 64 0.416NS
 Not on welfare135103
Employment status
 Employed 64 1819.165<0.0001
 Unemployed147149
Family
 Lived alone 9111523.596<0.0001
 Lived with relatives117 52

Statistics

Statview version 5.0 statistical software (SAS Institute Inc, Cary, NC, USA)13 was utilized for χ2 test, Kaplan–Meier analysis and Cox proportional hazards regression models were used for further exploration of post-treatment abstinence and certain baseline parameters as predictors of early mortality.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Of the 208 SHG subjects, 26 (12.5%) were unavailable for follow-up. Of the remaining, 177 were alive and five (2.4%) had died. Of the 167 NSHG subjects, 40 were alive, 47 had died (28.1%), and 80 (47.9%) were unavailable (Fig. 1). Differences in proportions of these outcomes were significant (χ2 = 57.261).

image

Figure 1. Study flow chart.

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Of the 52 deaths in the present study, 48 involved males with only four deaths among females. Mean age at death was 51.4 ± 10.9 years. Causes of death are summarized in Table 2. In our study, liver cirrhosis represented the most common cause of death.

Table 2. Cause of death among 52 alcoholics
Cause of deathSHG (n = 5)NSHG (n = 47)
  • Other disease: asthma, status epilepticus, myelodysplastic syndrome, etc.

  • SHG, Self-help group; NSHG, Non-self-help group; CVD, cerebrovascular disease.

Neoplasm0 4
CVD1 2
Liver cirrhosis215
Suicide0 4
Accidents0 4
Other disease210
Unidentified0 8

Figure 2 compares survival among the two groups. NSHG displayed a significantly decreased cumulative survival rate compared with SHG (P < 0.0001).

image

Figure 2. Survival experience for all subjects.

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Eight factors were considered as predictors: (i) age at enrollment (21–39 years, 40–59 years, or 60 years); (ii) sex (male or female); (iii) physical illness (present or absent); (iv) health insurance (on welfare or not on welfare); (v) employment status (employed or unemployed); (vi) family (lived alone or with relatives at enrollment); (vii) outpatient treatment or not after leaving the hospital; and (viii) SHG or NSHG.

All eight predictors were simultaneously entered into the Cox proportional hazards regression model. Through backwards stepwise iterations using the maximum partial likelihood ratio test, seven factors were eliminated from the equation as P-values since individual χ2-values exceeded 0.05. Global χ2-value before removal of any variable was 94.857, P < 0.0001. Only one predictor (SHG) was significant.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Our study investigated mortality status, cause of death, and predictors of mortality among 375 alcoholics recruited into a prospective study and followed-up between April 1994 and March 1999. Total mortality over 5 years was 13.8%, with 17 of the 52 deaths (32.7%) resulting from liver cirrhosis. Attendance of a SHG represented the most important predictor of mortality in subjects.

Mortality of alcoholics

Mortality rate (overall 13.8%: men 14.9%; women 7.4%) in this study was higher than those reported in other Japanese (3.8–10.8%)14–17 or foreign studies (10.9–12.0%).18–21 A number of factors may have been associated with this higher risk of mortality in our subjects. Some earlier Japanese studies22–25 have reported mean age at enrollment of 43–47 years, whereas, mean age at enrollment for our subjects was 48.8 years. Our subjects were, thus, slightly older than those of previous Japanese studies. Our subjects also appeared to display more physical illnesses and increased isolation compared to the subjects of earlier Japanese studies.

Other studies26–28 have reported that long history of alcohol abuse, poor health status, unemployment, high consumption, divorce, and lack of social supports are associated with increased mortality. While 36.5% (137/375) of our subjects were on welfare, several Japanese studies15,24,25 have reported that < 30% of subjects were on welfare. Individuals on welfare typically display poor economic status, increased isolation, and a presence of physical illness. About 40% of our subjects were poor, isolated and unwell. Several studies3,29,30 have demonstrated that increased age, increased alcohol consumption, lower income, decreased health status, and social isolation confer increased risks of death.

Survival analysis

Simple survival probabilities were obtained using the non-parametric approach of Kaplan–Meier. This univariate analysis was based on individual survival times and estimated probability of survival as a function of observation time. Comparisons of survival experiences between groups were accomplished using the generalized Wilcoxon (Breslow) model.13

In the present study, differences between SHG and NSHG groups were observed in relation to risk of mortality. These differences were attributed to a number of factors. In the analysis of SHG and NSHG groups, there was significance on living with family and employment at the enrollment between the SHG and the NSHG groups (Table 1). However, the factors did not contribute to the prognosis in the alcoholics (Table 3). Only attendance at the SHG groups was significant.

Table 3. Relative hazards and 95% confidence intervals for 375 participants in the Alcoholics cohort study, 1994–1999
 Simple variateMultiple variate
Relative hazard95% CIRelative hazard95% CI
  • Relative hazards were obtained using simple and multiple Cox proportional hazards models.

  • CI, confidence interval.

Age1.0230.998–1.0491.0140.987–1.042
Sex2.7600.860–8.8562.1850.650–7.345
Physical illness0.4690.268–0.8230.5890.318–1.094
Health insurance1.3400.742–2.4220.8450.441–1.618
Family0.3520.188–0.6610.6100.277–1.344
Employment status0.1820.057–0.5860.3630.107–1.230
Outpatient treatment0.6650.354–1.0691.1410.598–2.177
Self-help group0.0460.018–0.1160.0570.022–0.148

There was a similar previous study to our one.31 They reported that risk of death among alcoholics was higher in the NSHG than in the SHG, with 42 deaths among 120 SHG members, and 59 deaths among 125 NSHG members. However, no significant difference in risk of death was observed between SHG and NSHG in their report.

For the first time, our study clearly indicated that attendance at a SHG is the most important predictor to an alcoholic's prognosis.

Predictors of mortality in alcoholics

In the present study, only non-attendance at a SHG was associated with increased mortality. However, previous studies could not report clearly that the attendance at a SHG was associated with the prognosis in alcoholics.

Numerous studies have investigated the rate of death in alcoholics but few have investigated predictors. Several previous studies26,27,29 have identified age, health status, and marital status as three major factors associated with risk of death in alcoholics. However, some studies reported that age and physical illness were not associated with the prognosis in alcoholics. In our study, age and health status were not associated with the prognosis. There were different opinions about the factor of age and health status between the studies. In addition, regarding sex, health insurance, employment, and outpatient treatment, there were different opinions among researchers.9,15,16,24,25,28,30,32 Previous studies28,30 have reported separation, divorce, and effects of marital dissolution as associated with higher mortality in alcoholics. In the present study, we examined the factor of living alone or not. We assumed that living with someone, for example a spouse, parents, siblings, or friends, would be contributed to recovery and good prognosis in alcoholics.

There was significance in the factor of living alone or not at the enrollment between the SHG and the NSHG groups. However, there was no significance on the alcoholics prognosis. In other words, relatives and friends who live with alcoholics could provide support and encouragement to them, but whether the alcoholics prognosis is good or not would depend on the attendance at a SHG.

In fact, the 91 SHG persons who lived alone were supported by nurses and caseworkers of the Setagaya Department of Health and Welfare (Setagaya Area Network) and attended the SHG. Considering the 115 lonely NSHG at the enrollment and the 80 unknown NSHG persons at the end point, the mortality risk of our subjects may be reduced if they could be supported by network staff and be made to attend a SHG.

Worst case scenario

In the present study, the follow-up rate among patients who attended a SHG soon after the ATP (182/208, 87.5%) was much higher than that among NSHG patients soon after the ATP (40/167, 24.0%). It seems that patients who were not contacted, especially NSHG persons, may have been more likely to display a poor health status and suffer from alcohol-related diseases than patients who were not lost to follow-up. However, it is uncertain because we can not know where they are and confirm whether they are alive or not.

If we assume that all the 26 unknown in the SHG were dead and all the 80 unknown in the NSHG were alive, there would be 177 alive and 31 dead in the SHG, and 120 alive and 47 dead in the NSHG (Table 4). Therefore, there would be more dead in the NSHG than in the SHG. There would also be significance in the mortality status of the subjects between the SHG and the NSHG groups (χ2 = 9.09 P < 0.01). As a result, our conclusion will be confirmed if all information of our subjects was known.

Table 4. Worst simulation
 Alive (assumed)Dead (assumed)
  1. χ2 = 9.09; P < 0.01.

SHG17731
NSHG12047

CONCLUSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

The results of the present study support the notion that attending a SHG reduces the risk of premature death among alcoholics. We showed that attendance at a SHG reduces the risk of mortality among alcoholics in relation to social support, and clarified that SHG saved isolated alcoholics.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

The authors wish to thank Dr Toru Nishikawa, Dr Masaaki Matsushita and Dr Masamichi Sakaguchi for their support.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES
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