Stress-related psychiatric disorders across the life spa

Beekman, A.T.F.

Boschloo, L.

Brink, W. van den

Penninx, B.W.J.H.

Smit, J.H.

Veltman, D.J.

Vogelzangs, N.

van den Brink, W.

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Is alcohol consumption irrelevant to outcome in anxiety and depression? Reply

Boschloo, Lynn

Vogelzangs, Nicole

van den Brink, Wim

Smit, Johannes H.

Veltman, Dick J.

Beekman, Aartjan T. F.

Penninx, Brenda

VU Research Portal

VU Research PortalIs alcohol consumption irrelevant to outcome in anxiety and depression? ReplyBoschloo, L.; Vogelzangs, N.; van den Brink, W.; Smit, J.H.; Veltman, D.J.; Beekman,A.T.F.; Penninx, B.W.J.H.published inBritish Journal of Psychiatry2012DOI (link to publisher)10.1192/bjp.201.4.326adocument versionPublisher's PDF, also known as Version of recordLink to publication in VU Research Portalcitation for published version (APA)Boschloo, L., Vogelzangs, N., van den Brink, W., Smit, J. H., Veltman, D. J., Beekman, A. T. F., & Penninx, B.W. J. H. (2012). Is alcohol consumption irrelevant to outcome in anxiety and depression? Reply. British Journalof Psychiatry, 201(4), 326-327. https://doi.org/10.1192/bjp.201.4.326aGeneral rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.            • Users may download and print one copy of any publication from the public portal for the purpose of private study or research.            • You may not further distribute the material or use it for any profit-making activity or commercial gain            • You may freely distribute the URL identifying the publication in the public portal ?Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.E-mail address:vuresearchportal.ub@vu.nlDownload date: 21. May. 202110.1192/bjp.201.4.326aAccess the most recent version at DOI: 2012, 201:326-327.BJP Beekman and Brenda W. J. H. PenninxLynn Boschloo, Nicole Vogelzangs, Wim van den Brink, Johannes H. Smit, Dick J. Veltman, Aartjan T. F.Authors' replyReferenceshttp://bjp.rcpsych.org/content/201/4/326.2#BIBLThis article cites 0 articles, 0 of which you can access for free at: permissionsReprints/permissions@rcpsych.ac.ukwrite to To obtain reprints or permission to reproduce material from this paper, pleaseto this article atYou can respond http://bjp.rcpsych.org/cgi/eletter-submit/201/4/326from DownloadedThe Royal College of PsychiatristsPublished by  on October 30, 2013http://bjp.rcpsych.org/http://bjp.rcpsych.org/site/subscriptions/ go to: The British Journal of PsychiatryTo subscribe to Is alcohol consumption irrelevant to outcomein anxiety and depression?Boschloo and colleagues1 report that DSM-IV alcohol abuse is nota risk factor for unfavourable outcome in depression and anxietydisorders. This finding, which ostensibly conflicts with clinicalexperience, could easily be misunderstood to imply that non-dependent alcohol use is irrelevant in these disorders. We donot believe this is a true finding of the study. The paper addressesDSM-IV alcohol use disorder diagnosis at baseline as a riskfactor for poor outcome. It does not address continuing alcoholabuse and its effects on depression and anxiety. Latest alcoholconsumption statistics show that a substantial proportion of thepopulation drink alcohol heavily. In England, the latest estimatesare that 26% of men and 17% of women over the age of 16 drinkat levels that are hazardous or harmful to health.2 Clearly, only asmall proportion of these receive a diagnosis of alcohol usedisorder and there is no reason to believe that the situation inThe Netherlands is radically different. It would be expected thata significant proportion of the sample with no alcohol usedisorder diagnosis would be drinking alcohol at hazardous orharmful levels. Alcohol use disorder is therefore a poor markerfor alcohol consumption. Alcohol use disorder diagnosis cannothave an effect on the course of depressive or anxiety disordersas it is a theoretical construct. It is alcohol consumption thathas an effect. The current data are extracted from a larger studywith different aims3,4 and contain a number of flaws when usedto examine the effects of alcohol on depression and anxiety. Thereare no indications of levels of alcohol consumption other thanalcohol use disorder diagnosis and there are no data on alcoholdiagnosis at follow-up. There is no information about whattreatments the sample patients received, although this is likelyto have included advice to reduce alcohol consumption.Unsurprisingly, the study demonstrates that those with thepoorest depression and anxiety outcomes are those with a baselinediagnosis of alcohol dependence, with a stronger effect withincreasing severity of disorder. That is, those patients least likelyto have reduced their alcohol consumption during the studyhad the poorest outcomes. There is a puzzling finding in relationto severity of alcohol diagnosis: there are more patients in thesample with the more severe diagnosis of alcohol dependence thanwith the less severe diagnosis of alcohol abuse. The diagnosticcriteria for alcohol abuse are concerned largely with socialdysfunction, whereas those for alcohol dependence are concernedwith physical dependence and social dysfunction. It may be thatthe gap between the onset of moderate social dysfunction andthe onset of physical dependence or severe social dysfunction (asdetermined by the diagnostic criteria) represents a small part ofthe deterioration resulting from sustained heavy drinking, andtherefore is a poor indicator of population harmful drinking.The paper does convincingly suggest that severe alcoholdependence at baseline is a risk factor for poor outcome in anxietyand depression. It does not demonstrate that continued drinkingin other groups is irrelevant to outcome.1 Boschloo L, Vogelzangs N, van den Brink W, Smit JH, Veltman DJ,Beekman ATF, et al. Alcohol use disorders and the course of depressiveand anxiety disorders. Br J Psychiatry 2012; 200: 476–84.2 Health and Social Care Information Centre. Statistics on Alcohol: England,2012. Health and Social Care Information Centre, 2012.3 Penninx BWJH, Beekman ATF, Smit JH, Zitman FG, Nolen WA, Spinhoven P,et al. The Netherlands Study of Depression and Anxiety (NESDA): rationale,objectives and methods. Int J Methods Psychiatr Res 2008; 17: 121–40.4 Van Der Veen WJ, Van Der Meer K, Penninx BW. Screening for depressionand anxiety: correlates of non-response and cohort attrition in theNetherlands Study of Depression and Anxiety (NESDA). Int J MethodsPsychiatr Res 2009; 18: 229–39.John Bailey, Centre for Mental Health and Society, Bangor University, UK. Email:j.bailey@bangor.ac.uk; Rob Poole, Centre for Mental Health and Society, BangorUniversity; Susan Ruben, Betsi Cadwaladr University NHS Trust, North Wales;Catherine A. Robinson, Centre for Mental Health and Society, Bangor University,UKdoi: 10.1192/bjp.201.4.326Authors’ reply: We appreciate Bailey et al’s interest in ourstudy1 and respond to their comments regarding the founddifferential effects of alcohol dependence v. alcohol abuse andalcohol consumption.It is evident that heavy alcohol consumption has a majorimpact on public health because of its negative consequences onthe onset and course of various diseases.2 However, this doesnot necessarily imply that the level of alcohol consumption is alsocausally related to the onset and persistence of psychopathologysuch as depression and anxiety. For example, Haynes et al3 showedthat heavy alcohol consumption was not a risk factor for the onsetof depression and anxiety in a national sample of adults in GreatBritain. Furthermore, additional analyses in our sample showedthat neither heavy alcohol consumption at baseline (odds ratio(OR) = 0.98, 95% CI 0.71–1.36) nor at 2-year follow-up(OR = 0.98, 95% CI 0.69–1.41) predicted the persistence ofdepression and anxiety.In contrast, DSM-IV alcohol dependence has strong links withdepression and anxiety. For example, previous epidemiologicalstudies have demonstrated robust cross-sectional associations4,5and, in addition, our study showed that alcohol dependence atbaseline was an important risk factor for the persistence ofdepression and anxiety during 2-year follow-up (OR = 1.69, 95%CI 1.04–2.75, adjusted for basic covariates).1 Additional analysesfurther showed that this association remained significant aftercontrolling for the possible effects of alcohol consumption(OR = 2.05, 95% CI 1.19–3.53, additionally adjusted for alcoholconsumption). This indicates that impairments related to alcoholdependence, rather than consumption per se, have an effect on thecourse of depression and anxiety. Support for this hypothesis wasalso provided by our finding that persistence rates of depressionand anxiety increased with the severity of alcohol dependence(i.e. number of alcohol dependence criteria).1Previous studies have raised the question whether DSM-IValcohol abuse should be considered a genuine psychiatric disorderas it was characterised by low severity in the general populationand showed limited reliability and validity (see Boschloo et al1for a discussion on this topic). This notion received furthersupport by our finding that 95.7% of patients with alcohol abusemet only one of four abuse criteria.1 Additional analyses showed326Edited by Kiriakos Xenitidis andColin CampbellContents& Is alcohol consumption irrelevant to outcomein anxiety and depression?& Depression in the workplace:what is depression?& Severe mental illness in prisoners worldwideThe British Journal of Psychiatry (2012)201, 326–328Correspondencethat alcohol abuse was not related to impairments in dailyfunctioning (assessed with the World Health OrganizationDisability Assessment Schedule II) and had a favourable course(remission rate after 2 years: 93.5%). Apparently, alcohol abuseis characterised by only minimal alcohol-related impairments,which may clarify our finding that it was not related to thepersistence of depression and anxiety. Note that alcohol abuse inour sample of out-patients with depression or anxiety or in thegeneral population might differ substantially from alcohol abusein clinical samples of severe abusers with regard to associatedlevels of impairment.Taken together, these findings emphasise the importance ofseverity indicators, rather than dichotomous diagnoses of alcoholdependence or abuse, in the assessment of alcohol problems. Thisis in line with the proposal of the DSM-5 Work Group todistinguish different levels of severity within the diagnosis of analcohol use disorder (www.dsm5.org).1 Boschloo L, Vogelzangs N, Van den Brink W, Smit JH, Veltman DJ,Beekman ATF, et al. Alcohol use disorders and the course of depressiveand anxiety disorders. Br J Psychiatry 2012; 200: 476–84.2 World Health Organization. Global Status Report on Alcohol and Health. WHO,2011.3 Haynes JC, Farrell M, Singleton N, Meltzer H, Araya R, Lewis G, Wiles NJ.Alcohol consumption as a risk factor for anxiety and depression. Resultsfrom the longitudinal follow-up of the National Psychiatric Morbidity Survey.Br J Psychiatry 2005; 187: 544–51.4 Boschloo L, Vogelzangs N, Smit JH, Van den Brink W, Veltman DJ,Beekman AT, et al. Comorbidity and risk indicators for alcohol usedisorders among persons with anxiety and/or depressive disorders:findings from the Netherlands Study of Depression and Anxiety (NESDA).J Affect Disord 2011; 131: 233–42.5 Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability,and comorbidity of DSM-IV alcohol abuse and dependence in the UnitedStates: results from the National Epidemiologic Survey on Alcohol andRelated Conditions. Arch Gen Psychiatry 2007; 64: 830–42.Lynn Boschloo, PhD, Department of Psychiatry and EMGO Institute for Health andCare Research, VU University Medical Centre, Amsterdam, and Department ofPsychiatry, University Medical Centre, Hanzeplein 1, Groningen, The Netherlands;Email: l.boschloo@umcg.nl; Nicole Vogelzangs, PhD, Department of Psychiatry andEMGO Institute for Health and Care Research, VU University Medical Centre,Amsterdam; Wim van den Brink, PhD, MD, Department of Psychiatry, AcademicMedical Centre, University of Amsterdam, Amsterdam; Johannes H. Smit, PhD,Department of Psychiatry and EMGO Institute for Health and Care Research, VUUniversity Medical Centre, Amsterdam; Dick J. Veltman, PhD, MD, Department ofPsychiatry, VU University Medical Centre, Amsterdam; Aartjan T. F. Beekman, PhD,MD, Department of Psychiatry and EMGO Institute for Health and Care Research, VUUniversity Medical Centre, Amsterdam; Brenda W. J. H. Penninx, PhD, Departmentof Psychiatry and EMGO Institute for Health and Care Research, VU University MedicalCentre, Amsterdam, Department of Psychiatry, University Medical Centre, Groningen,and Department of Psychiatry, Leiden University Medical Centre, The Netherlandsdoi: 10.1192/bjp.201.4.326aDepression in the workplace: what is depression?As a former consultant occupational psychiatrist to theMetropolitan Police and a contributor to the Black & Frostreport,1 I would like to point to the basic flaw in the paper byGilbody et al.2In Gilbody et al’s account of ‘depression in the workplace’, theytake ‘depression’ as a given, requiring no further explanation,yet there is currently no psychiatric category so bloated andsubject to overdiagnosis. My experience of 900 assessments ofindividuals at the Metropolitan Police, 99% of whom werecertificated as being ‘off sick’ with depression or one of the other‘common mental disorders’, showed that the psychiatrisation ofnon-specific symptoms led routinely to unduly prolonged sicknessabsence and thus unnecessary disability.3 Sickness absence wasstrongly associated with workplace problems and other situationalstresses: dislocation to a psychiatric arena frequently paralysed thepractical problem-solving that would have normalised the situa-tion in timely fashion. I found that National Health Service(NHS) mental health services were disconnected from the occupa-tional aspects of patients’ lives, and saw diagnosis and treatment ashaving a life of its own. Antidepressants and periodic out-patientappointments did not seem a model that got many people back towork. Naturally, I support Gilbody et al’s advocacy of closerrelations with the workplace but NHS services will continue tobe as much part of the problem as of the solution without a reviewof the narrowly biomedical culture of much psychiatric practice.Last, Gilbody et al see hope in the Layard Improving Access toPsychological Therapies (IAPT) programme. It is laughable hubrisfor the profession to imagine that large numbers of very hetero-geneous people, many of whom have been out of the workplacefor years, can be gathered together under the rubric of ‘commonmental disorder’ and restored to full productivity via a fewsessions of talk therapy.1 Black C, Frost D. Health at Work – An Independent Review of SicknessAbsence. TSO (The Stationery Office), 2011.2 Gilbody S, Bower P, Rick J. Better care for depression in the workplace:integrating occupational and mental health services. Br J Psychiatry 2012;200: 442–3.3 Summerfield D. Metropolitan Police blues: protracted sickness absence, illhealth retirement, and the occupational psychiatrist. BMJ 2011; 342: 950–2.Derek Summerfield, Consultant Psychiatrist, Institute of Psychiatry, King’s CollegeLondon, UK. Email: Derek.Summerfield@slam.nhs.ukdoi: 10.1192/bjp.201.4.327Severe mental illness in prisoners worldwideWe read with interest the review article by Fazel & Seewald.1 Theauthors conclude that severe mental illness is more prevalent inprisoners in low- and middle-income (LAMI) countries than inhigh-income countries. This may be related to fewer opportunitiesand services for diverting offenders to health services, a strongerrelationship between mental illness and criminality, and differentsociocutural factors (e.g. poorer legal representation for thementally ill in LAMI countries).We examined in an earlier study the relationship betweenmental illness and criminality in pre-trial reported Antilleandefendants in The Netherlands and The Netherlands Antilles.2Defendants who are suspected to have a mental illness areexamined pre-trial by a psychiatrist or psychologist both in TheNetherlands and The Netherlands Antilles, before diversion tomental health services takes place. We found no significantdifference in the prevalence of psychotic disorders among pre-trialreported Antillean suspects in The Netherlands and TheNetherlands Antilles (14.4% v. 15.1%) and no significantdifference in the prevalence of defendants deemed unaccountabledue to a mental disorder (3.9% v. 4.0%). There was, however, amuch lower registered crime rate of Antilleans in The NetherlandsAntilles than The Netherlands (11 v. 113 offences per year per1000 persons; P50.001) and a much higher rate of pre-trialreports in The Netherlands Antilles than The Netherlands (74 v.8 per 1000 Antillean defendants; P50.001). Antilleans living inThe Netherlands Antilles thus have a low crime rate and a highpre-trial report rate when indicted of a crime compared withAntilleans in The Netherlands, indicating that they are morefrequently suspected to have a mental illness.This finding is in line with the earlier formulated rule ofthumb that the frequency of mental illness is higher in countrieswith low crime rates.3,4 Indeed, the LAMI countries included inFazel & Seewald’s review have a combined prison population rate327Correspondenceof 77 per 100 000, considerably less than the worldwide prisonpopulation rate of 145 per 100 000.5 The higher prevalence ofsevere mental illness in prisoners in LAMI countries may beexplained by lower rates of crime and imprisonment. If so, therelationship between mental illness and crime is not stronger inLAMI countries, but weaker in high-income countries.1 Fazel S, Seewald K. Severe mental illness in 33 588 prisoners worldwide:systematic review and meta-regression analysis. Br J Psychiatry 2012; 200:364–73.2 Vinkers DJ, Heytel FG, Matroos GM, Hermans KM, Hoek HW. Pre-trialpsychiatric reports on Antillean suspected offenders in the Netherlands andon the Dutch Antilles. Tijdschr Psychiatr 2010; 52: 745–52.3 Large M, Smith G, Swinson N, Shaw J, Nielssen O. Homicide due to mentaldisorder in England and Wales over 50 years. Br J Psychiatry 2008; 193:130–3.4 Coid J. The epidemiology of abnormal homicide and murder followed bysuicide. Psychol Med 1983; 13: 855–6.5 Walmsley R. World Prison Population List (Eighth Edition). InternationalCentre for Prison Studies, King’s College London School of Law, 2009.David J. Vinkers, MD, PhD, Netherlands Institute for Forensic Psychiatry andPsychology, The Netherlands. Email: d.vinkers@dji.minjus.nl; Micha van de Vorst,MSc, Psychiaters Maatschap Antillen, Curacao. Hans W. Hoek, MD, PhD, ParnassiaBavo Psychiatric Institute, The Hague, Department of Psychiatry, University MedicalCenter Groningen, University of Groningen, The Netherlands, and Department ofEpidemiology, Mailman School of Public Health, Columbia University, New York, USAdoi: 10.1192/bjp.201.4.327a328CorrespondenceCorrectionNegative childhood experiences and mental health: theoretical,clinical and primary prevention implications. BJP, 200, 89–91.Reference 5 should read: Kingdon D, Sharma T, Hart D, theSchizophrenia Subgroup of The Royal College of Psychiatrists’Changing Minds Campaign. What attitudes do psychiatrists holdtowards people with mental illness? Psychiatr Bull 2004; 28: 401–6.doi: 10.1192/bjp.201.4.328

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