Recovery in a tribal community

Interesting findings from a study of remission from alcoholism in a Native American community:

A surprising and novel finding of this study is that self-reported depression and anxiety symptoms do play a significant role in increasing and decreasing, respectively, the likelihood of remission. These are not depression and anxiety symptoms occurring in the context of alcohol withdrawal, because a similar question asking whether withdrawal had ever caused depression or anxiety symptoms did not appear in the final logistic regression model. Why self-reported depression and anxiety caused by drinking should be significantly associated with remission, especially in light of the absence of association of independent or substance-induced anxiety and affective disorders with remission, is unclear. It may be that insight about the nature of the relationship between drinking and depression and anxiety is a critical element in promoting or inhibiting remission. Why self-reported alcohol-induced depression would increase while self-reported alcohol induced anxiety would decrease the likelihood of remission is also unclear. The former is consistent with findings that insight promotes increased compliance with treatment and remission of other psychiatric disorders (37–39). The latter is consistent with the hypothesis that individuals with alcohol dependence and alcohol-induced anxiety symptoms are more likely to continue drinking, perhaps as a means to self-medicate those symptoms. Both raise the possibility that education about the depression and anxious effects of alcohol and alternative ways of dealing with anxiety symptoms that accompany alcohol dependence may have an important role in treatment and community prevention programs in this high-risk population.

We also tested whether factors associated with remission of alcohol dependence were also associated with the survival of alcohol dependence. Two factors significantly associated with remission (being married and having self-reported depression symptoms from drinking) were also significantly associated with a shorter duration of alcohol dependence, and two factors associated with nonremission (continuing to drink despite medical problems and having self-reported anxiety symptoms from drinking) were also significantly associated with a longer duration of alcohol dependence. Advancing age and younger age at onset of alcohol dependence were both associated with increased likelihood of remission. However, both advancing age and younger age at onset of alcohol dependence were associated with increased duration of alcohol dependence. These data are consistent with previous findings in this group that alcohol dependence runs a typical clinical course that includes duration as well as symptom profile (3). These data are not consistent with the notion that, from the standpoint of remission, there may be two groups of alcohol-dependent individuals: those with early onset who have a shorter course of alcoholism and those with later onset who have a longer course, which has been suggested for other populations (16, 40).

This is a study of a specific population and may not be tranferable to other groups of alcoholics. The finding is not shocking if you’ve read this blog.

The article offers other interesting and hopeful findings:

In this study, the rate of 6-month full remission from DSM-III-R alcohol dependence with 1-month clustering of 59% is comparable to the U.S. epidemiological rate of 1 year prior to past year, full remission from DSM-IV alcohol dependence of 48% (14), the 1-year partial remission rate of 64% in a German representative population sample (17), and the 1-year full remission rate from alcohol abuse and dependence of 53% found in Ontario, Canada (16). Despite the high rate of 1-month clustered DSM-III-R alcohol dependence of 49% in this group, the rate of full remission is comparable to studies of predominantly European ancestry populations.

Several factors associated with full remission in this American Indian group are consistent with factors associated with full remission in the general U.S. population. Our findings are consistent with the findings of Dawson and colleagues (14) that abstinent and nonabstinent recovery in the general U.S. population are associated with female gender, increasing age, and being married, but not with tobacco use, dependent use of illicit drugs, and having any lifetime anxiety or affective disorder. Our findings are also consistent with Schuckit and colleagues (30), who found that episodes of 3-month abstinence in a mixed treatment and nontreatment group were associated with female gender, older age, ever having been married, and younger age of onset of alcohol dependence, but not with a primary diagnosis of antisocial personality disorder.

Increasing likelihood of remission with advancing age in this American Indian group is consistent with the “aging out” phenomenon described in the Navajo (5, 23). Why “aging out” occurs in American Indians and other ethnicities is unclear. Alcohol dependence may biologically run its course in a proportion of alcohol dependents, and/or the accumulating psychosocial burden of alcohol dependence may prompt increasingly successful attempts at cutting back on drinking. In addition, as age advances, individuals with alcohol dependence, as well as those without, may develop new work, social, and family networks (19) that play a role in reducing drinking. The consistent association of remission with marriage (14, 18, 36) suggests that the social support and limit setting that can come from a spouse are important factors in promoting remission.

Does this suggest that the high prevalence in tribal communities may be due to multiple pathways to addiction (not just genetic vulnerability) and that there may be multiple types of alcoholism at play? I’m not sure.  Maybe. This will be interesting to watch.