Marcin Wojnar

Sleep problems and suicidality in the National Comorbidity Survey Replication

OBJECTIVE Links between sleep problems and suicidality have been frequently described in clinical samples; however, this issue has not been well-studied in the general population. Using data from a nationally representative survey, we examined the association between self-reported sleep difficulties and suicidality in the United States. METHODS The WHO Composite International Diagnostic Interview was used to assess sleep problems and suicidality in the National Comorbidity Survey Replication (NCS-R). Relationships between three measures of sleep (difficulty initiating sleep, maintaining sleep, early morning awaking), and suicidal thoughts, plans, and attempts were assessed in logistic regression analyses, while controlling for demographic characteristics, 12-month diagnoses of mood, anxiety and substance use disorders, and chronic health conditions. RESULTS In multivariate models, the presence of any of these sleep problems was significantly related to each measure of suicidality, including suicidal ideation (OR=2.1), planning (OR=2.6), and suicide attempt (OR=2.5). Early morning awakening was associated with suicidal ideation (OR=2.0), suicide planning (OR=2.1), and suicide attempt (OR=2.7). Difficulty initiating sleep was a significant predictor of suicidal ideation and planning (ORs: 1.9 for ideation; 2.2 for planning), while difficulty maintaining sleep during the night was a significant predictor of suicidal ideation and suicide attempts (ORs: 2.0 for ideation; 3.0 for attempt). CONCLUSIONS Among community residents, chronic sleep problems are consistently associated with greater risk for suicidality. Efforts to develop comprehensive models of suicidality should consider sleep problems as potentially independent indicators of risk.

Association Between Val66Met Brain-Derived Neurotrophic Factor (BDNF) Gene Polymorphism and Post-Treatment Relapse in Alcohol Dependence

BACKGROUND The purpose of this study was to examine relationships between genetic markers of central serotonin (5-HT) and dopamine function, and risk for post-treatment relapse, in a sample of alcohol-dependent patients. METHODS The study included 154 patients from addiction treatment programs in Poland, who met DSM-IV criteria for alcohol dependence. After assessing demographics, severity of alcohol use, suicidality, impulsivity, depression, hopelessness, and severity of alcohol use at baseline, patients were followed for approximately 1 year to evaluate treatment outcomes. Genetic polymorphisms in several genes (TPH2, SLC6A4, HTR1A, HTR2A, COMT, and BDNF) were tested as predictors of relapse (defined as any drinking during follow-up) while controlling for baseline measures. RESULTS Of 154 eligible patients, 123 (80%) completed follow-up and 48% (n = 59) of these individuals relapsed. Patients with the Val allele in the Val66Met BDNF polymorphism and the Met allele in the Val158Met COMT polymorphism were more likely to relapse. Only the BDNF Val/Val genotype predicted post-treatment relapse [odds ratio (OR) = 2.62; p = 0.019], and time to relapse (OR = 2.57; p = 0.002), after adjusting for baseline measures and other significant genetic markers. When the analysis was restricted to patients with a family history of alcohol dependence (n = 73), the associations between the BDNF Val/Val genotype and relapse (OR = 5.76, p = 0.0045) and time to relapse (hazard ratio = 4.93, p = 0.001) were even stronger. CONCLUSIONS The Val66Met BDNF gene polymorphism was associated with a higher risk and earlier occurrence of relapse among patients treated for alcohol dependence. The study suggests a relationship between genetic markers and treatment outcomes in alcohol dependence. Because a large number of statistical tests were conducted for this study and the literature on genetics and relapse is so novel, the results should be considered as hypothesis generating and need to be replicated in independent studies.

Impulsive and non-impulsive suicide attempts in patients treated for alcohol dependence

BACKGROUND Suicidal behavior has been recognized as an increasing problem among alcohol-dependent subjects. The aim of the study was to identify correlates of impulsive and non-impulsive suicide attempts among a treated population of alcohol-dependent patients. METHODS A total of 154 patients with alcohol dependence consecutively admitted for addiction treatment participated in the study. Suicidal behavior was assessed together with severity of alcohol dependence, childhood abuse, impulsivity, and family history. A stop-signal procedure was used as a behavioral measure of impulsivity. RESULTS AND CONCLUSIONS Lifetime suicide attempts were reported by 43% of patients in alcohol treatment; of which 62% were impulsive. Compared to patients without a suicide attempt, those with a non-impulsive attempt were more likely to have a history of sexual abuse (OR=7.17), a family history of suicide (OR=4.09), and higher scores on a personality measure of impulsiveness (OR=2.27). The only significant factor that distinguished patients with impulsive suicide attempts from patients without a suicide attempt and from patients with a non-impulsive suicide attempt was a higher level of behavioral impulsivity (OR=1.84-2.42). LIMITATIONS Retrospective self-report of suicide attempts and family history. Lack of diagnostic measure.

Vitamin D and the central nervous system.

Vitamin D is formed in human epithelial cells via photochemical synthesis and is also acquired from dietary sources. The so-called classical effect of this vitamin involves the regulation of calcium homeostasis and bone metabolism. Apart from this, non-classical effects of vitamin D have recently gained renewed attention. One important yet little known of the numerous functions of vitamin D is the regulation of nervous system development and function. The neuroprotective effect of vitamin D is associated with its influence on neurotrophin production and release, neuromediator synthesis, intracellular calcium homeostasis, and prevention of oxidative damage to nervous tissue. Clinical studies suggest that vitamin D deficiency may lead to an increased risk of disease of the central nervous system (CNS), particularly schizophrenia and multiple sclerosis. Adequate intake of vitamin D during pregnancy and the neonatal period seems to be crucial in terms of prevention of these diseases.

General Practitioners Recognizing Alcohol Dependence: A Large Cross-Sectional Study in 6 European Countries

PURPOSE Although alcohol dependence causes marked mortality and disease burden in Europe, the treatment rate is low. Primary care could play a key role in reducing alcohol-attributable harm by screening, brief interventions, and initiating or referral to treatment. This study investigates identification of alcohol dependence in European primary care settings. METHODS Assessments from 13,003 general practitioners, and 9,098 interviews (8,476 joint number of interviewed patients with a physician’s assessment) were collected in 6 European countries. Alcohol dependence, comorbidities, and health service utilization were assessed by the general practitioner and independently using the Composite International Diagnostic Interview (CIDI) and other structured interviews. Weighted regression analyses were used to compare the impact of influencing variables on both types of diagnoses. RESULTS The rate of patients being identified as alcohol dependent by the CIDI or a general practitioner was about equally high, but there was not a lot of overlap between cases identified. Alcohol-dependent patients identified by a physician were older, had higher rates of physicial comorbidity (liver disease, hypertension), and were socially more marginalized, whereas average consumption of alcohol and mental comorbidity were equally high in both groups. CONCLUSION General practitioners were able to identify alcohol dependence, but the cases they identified differed from cases identified using the CIDI. The role of the CIDI as the reference standard should be reexamined, as older alcohol-dependent patients with severe comorbidities seemed to be missed in this assessment.

Prescription Sleeping Pills, Insomnia, and Suicidality in the National Comorbidity Survey Replication

BACKGROUND Sedative-hypnotics have been associated with suicide attempts and completed suicides in a number of toxicologic, epidemiologic, and clinical studies. Most studies, however, inadequately address confounding by insomnia, which not only is a component of many mental health disorders that increase suicidal risk, but also is independently associated with suicidality. Moreover, the association of nonbenzodiazepine benzodiazepine receptor agonists (NBRAs) with suicidality has not been specifically studied in the US general population. OBJECTIVE The purpose of this study was to assess the independent contribution of prescription sedative-hypnotic use, particularly the NBRAs, to suicidal ideas, plans, and suicide attempts in the general US population, after adjusting for insomnia and other confounding variables. METHOD Secondary analyses of National Comorbidity Survey Replication data for 5,692 household respondents interviewed between 2001 and 2003 assessed the cross-sectional relationships between prescription sedative-hypnotic use and suicidality in the previous 12 months. Multivariate, hierarchical logistic regression analyses controlled for symptoms of insomnia, past-year mental disorders, lifetime chronic physical illnesses, and demographic variables. RESULTS Prescription sedative-hypnotic use in the past year was significantly associated with suicidal thoughts (adjusted odds ratio [AOR] = 2.2; P < .001), suicide plans (AOR = 1.9; P < .01), and suicide attempts (AOR = 3.4; P < .01). It was a stronger predictor than insomnia for both suicidal thoughts and suicide attempts and significantly improved the fit of these regression models (suicidal thoughts, P < .01; suicide attempts, P < .05). CONCLUSIONS Prescription sleeping pills, as exemplified by zolpidem and zaleplon, are associated with suicidal thoughts and suicide attempts during the past 12 months, but no evidence of causality was provided by this study. Clinical practitioners should recognize that patients taking similar types of sedative-hypnotics have a marker of increased risk for suicidality.

Inverse association of the obesity predisposing FTO rs9939609 genotype with alcohol consumption and risk for alcohol dependence

AIMS To investigate whether the FTO rs9939609 A allele (a risk factor for obesity) is associated with measures of alcohol consumption. DESIGN Population-based cross-sectional study and two case-control studies. SETTING Poland and the Warsaw area. PARTICIPANTS A total of 6584 subjects from the WOBASZ survey and two cohorts of alcohol-dependent patients (n = 145 and n = 148). MEASUREMENTS Questionnaire data analysis, rs9939609 typing. FINDINGS Among individuals drinking alcohol, the obesity-associated AA genotype was also associated with lower total ethanol consumption [sex-, age- and body mass index (BMI)-adjusted difference: 0.21 g/day, P = 0.012] and distinct drinking habits with relatively low frequency of drinks but larger volume consumed at a time as evidenced by (i) association between AA and frequency/amount of typical drinks (P = 0.023, multiple logistic regression analysis); (ii) inverse correlation between AA and drink frequency adjusted for drink size (P = 0.007 for distilled spirits, P = 0.018 for beer); (iii) decreased frequency of AA [odds ratio (OR) = 0.46, P = 0.0004] among those who drank small amounts of distilled spirits (≤ 100 ml at a time) but frequently (≥ 1-2 times/week). A decrease of AA was also found in both cohorts of alcohol-dependent patients versus geographically matched subjects from WOBASZ yielding a pooled estimate of OR = 0.59, confidence interval (CI): 0.40-0.88, P = 0.008. Exploratory analysis showed that those with rs9939609 AA reported lower (by 1.22) mean number of cigarettes/day during a year of most intense smoking (P = 0.003) and were older at start of smoking by 0.44 years (P = 0.016). CONCLUSIONS The FTO AA genotype, independently from its effect on BMI, is associated with measures of ethanol consumption and possibly tobacco smoking.

Cognitive functions in abstinent alcohol-dependent patients

The objective of this cross-sectional study was to compare cognitive functioning of abstaining alcohol-dependent (AD) male patients and healthy controls as well as to investigate whether their cognitive performance varied by abstinence length. Forty-two maintaining abstinent (AD) patients and 34 healthy controls were examined. Tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were used to assess cognitive functions. Differences in cognitive performance were found between AD patients and healthy controls. Nonverbal tasks in cognitive domains such as attention, visual memory and working memory were impaired in AD patients who presented deficits in visual episodic memory, had slower reaction time and reduced working memory span. Patients who were abstinent for less than one year made more errors in both attentional set shifting and working memory tests than healthy controls and patients with longer durations of abstinence. Impairments identified in multiple cognitive domains in abstinent alcohol-dependent subjects suggest functional deficits in extensive brain networks connecting interrelated brain structures. Attentional control and spatial working memory were less impaired in those AD patients who maintained abstinence for at least one year.

Prevalence of Past Year Assault Among Inner-City Emergency Department Patients

STUDY OBJECTIVE We determine the rates of past year nonpartner violent assault, both victimization and aggression, and assess variables associated with nonpartner violent assault, particularly with regard to substance use. METHODS A cross-sectional computerized standardized survey study was conducted to assess nonpartner violent assault, physical and mental health, and substance use among patients presenting to an inner-city ED during 2 years. Patients (aged 19 to 60 years) with normal vital signs in an urban emergency department (ED) from 9 am to 11 pm were eligible; pregnant patients and those with a chief complaint of psychiatric evaluation were excluded. Logistic regression analyses were conducted to predict any nonpartner violent assault. RESULTS Ten thousand seven hundred forty-four patients were enrolled (80% response rate); 14% of the sample reported any past year nonpartner violent assault (9% perpetration; 11% victimization). Findings from regression analyses found that participants with any past year nonpartner violent assault (victimization or aggression) were more likely than their counterparts to be men (2.2), to be single (1.5), to be unemployed (1.1), to present to the ED for injury (1.9), and to report poor physical health (1.3) or poor mental health (1.9). They were less likely to be black (0.8), or older (0.95). Alcohol use (1.7), marijuana use (2.4), cocaine use (3.1), prescription drug use (1.4), and past treatment (1.7) were associated with experiencing past year nonpartner violent assault. CONCLUSION Fourteen percent of patients seeking care in this inner-city ED experience violence with a nonpartner. Substance use-specifically cocaine-was the strongest predictor of any nonpartner violent assault.

Alcohol use disorders in primary health care: what do we know and where do we go?

AIMS To analyze the current paradigm and clinical practice for dealing with alcohol use disorders (AUD) in primary health care. METHODS Analyses of guidelines and recommendations, reviews and meta-analyses. RESULTS Many recommendations or guidelines for interventions for people with alcohol use problems in primary health care, from hazardous drinking to AUD, can be summarized in the SBIRT principle: screening for alcohol use and alcohol-related problems, brief interventions for hazardous and in some cases harmful drinking, referral to specialized treatment for people with AUD. However, while there is some evidence that these procedures are effective in reducing drinking levels, they are rarely applied in clinical practice in primary health care, and no interventions are initiated, even if the primary care physician had detected problems or AUD. Rather than asking primary health care physicians to conduct interventions which are not typical for medical doctors, we recommend treatment initiation for AUD at the primary health care level. AUD should be treated like hypertension, i.e. with regular checks for alcohol consumption, advice for behavioral interventions in case of consumption exceeding thresholds, and pharmaceutical assistance in case the behavioral interventions were not successful. Minimally, alcohol consumption should be screened for in all situations where there is a co-morbidity with alcohol being a potential cause (such as hypertension, insomnia, depression or anxiety disorders). CONCLUSIONS A paradigm shift is proposed for dealing with problematic alcohol consumption in primary health care, where initiation for treatment for AUD is seen as the central element.