Gea A, Beunza JJ, Estruch R, et al (17 authors). Alcohol intake, wine consumption and the development of depression: the PREDIMED study. BMC Medicine 2013. Advanced publication, released 29 August 2013.
Background: Alcoholic beverages are widely consumed. Depression, the most prevalent mental disorder worldwide, has been related to alcohol intake. We aimed to prospectively assess the association between alcohol intake and incident depression using repeated measurements of alcohol intake.
Methods: We followed-up 5,505 high-risk men and women (55 to 80 y) of the PREDIMED Trial for up to seven years. Participants were initially free of depression or a history of depression, and did not have any history of alcohol-related problems. A 137-item validated food frequency questionnaire administered by a dietician was repeated annually to assess alcohol intake. Participants were classified as incident cases of depression when they reported a new clinical diagnosis of depression, and/or initiated the use of antidepressant drugs. Cox regression analyses were fitted over 23,655 person-years.
Results: Moderate alcohol intake within the range of 5 to 15 g/day was significantly associated with lower risk of incident depression (hazard ratio (HR) and 95% confidence interval (95% CI) = 0.72 (0.53 to 0.98) versus abstainers). Specifically, wine consumption in the range of two to seven drinks/week was significantly associated with lower rates of depression (HR (95% CI) = 0.68 (0.47 to 0.98)).
Conclusions: Moderate consumption of wine may reduce the incidence of depression, while heavy drinkers seem to be at higher risk.
(It is noted that two of the 17 authors of this paper are members of this Forum. They have not provided any comments for this critique.)
This appears to be a well-done analysis of the relation of moderate drinking with depression among adult subjects at high-risk of cardiovascular disease. There were appropriate restrictions to entry into the study cohort and important sensitivity analyses were carried out. The analyses are based almost exclusively on “moderate” drinkers, as people exceeding certain amounts of alcohol or testing positive on the CAGE questionnaire (a measure of alcohol misuse) were excluded.
It was a large prospective study, based on data from more than 5,000 55-80 years old subjects who were followed for up to 7 years for the initial development of depression. A total of 443 subjects had a clinical diagnosis of depression made or began to use anti-depressive medications during follow up. The subjects in this study were at increased risk of cardiovascular disease due to diabetes (about one-half of participants) or other risk factors. Essentially all were primarily wine drinkers.
There were repeated assessments of alcohol consumption, every two years, with the development of depression only within the second year after each alcohol assessment counted (to prevent reverse causation). A rather complete list of potentially confounding variables was available. In sensitivity analyses, the authors evaluated lifetime non-drinkers vs current non-drinkers, men vs women, subjects by age groups, excluding diabetics, etc. Only the latter (diabetes) changed the estimates of effect. The key findings were that subjects reporting >5-15 grams/day of total alcohol intake, and wine drinkers of 2-7 drinks/week, were at a lower risk of developing depression than were non-drinkers.
Specific Comments by Forum Reviewers: Forum reviewers were impressed by many aspects of this study: the large sample size, the repeated assessments of alcohol intake, appropriate analytic techniques. They thought that being able to provide updated alcohol/wine consumption estimates added to the importance of the study, especially since heavy drinking can lead to depression, and depression can get people to start to drink heavily. Reviewer Svilaas stated: “The strength of the study is the high number of participants, that it is prospective, and that annually a long and complete food frequency questionnaire was used. This should have provided very reliable estimates of alcohol intake.”
Forum members appreciated that this study does not provide data to judge the effects of alcohol misuse and depression, as most heavy drinkers were excluded. Instead, it provides valuable data on the relation of moderate drinking, especially of wine, to the development of depression.
Some Forum members did not think that the analyses necessarily supported the conclusions of the authors that moderate drinking lowers the risk of depression. Said Reviewer Finkel: “I cannot support the statements of the authors of a physiological parallel between cardiovascular disease and depressive disease in their relationships to drinking. Further, drinking is often a symptom of depression, likely an attempt at self-medication, and drawing a deeper significance from the conflation of the two seems to me untenable.”
Reviewer Van Velden thought that this was a well-done study, but believed that it is difficult to eliminate possible confounders. “Moderate alcohol drinkers may be healthiers and happier than heavy drinkers. A healthy lifestyle, where moderate alcohol consumption is a part of life, may be the possible explanation for the lower incidince of depression.”
Forum member De Gaetano stated: “Depression is a delicate matter and moderate wine consumption in a Mediterranean Country is difficult to dissociate from the population’s dietary habits. Thus the role of possible confounders remains potentially high. Possibly, one might conclude that moderate wine consumption, in the context of a Mediterranean-Diet dietary habit, is associated with lower incidence of depression. “
There is a large literature relating heavy alcohol consumption to depression: most studies show that heavy drinkers tend to be depressed, and depressed people may self-medicate with large amounts of alcohol. This large prospective study of subjects at high risk of cardiovascular disease has shown that “moderate” drinkers, especially wine drinkers (the majority of their subjects), were at lower risk of developing depression during 7 years of follow up than were non-drinkers. An important aspect of this study is indeed that the analyses were based on moderate drinkers, as people exceeding certain amounts of alcohol or testing positive on the CAGE questionnaire (a measure of alcohol misuse) were excluded.
Strengths of the study include it being a large prospective study, with more than 5,000 subjects, aged 55-80 years at baseline, who were followed for up to 7 years for the initial development of clinical depression (which was diagnosed in 443 instances). Especially important was the ability of the investigators to have repeated assessments of alcohol consumption, every two years. A rather complete list of potentially confounding variables was available. The key findings of the study were that subjects reporting >5-15 grams/day of total alcohol intake, and wine drinkers of 2-7 drinks/week, were at a lower risk of developing depression than were non drinkers.
Some Forum members remained concerned that there may have been residual confounding by other lifestyle habits, and that the results may apply primarily to subjects who are also following a Mediterranean-type diet and lifestyle. Also, data were not available to evaluate the relation of heavy drinking or alcoholism to depression. However, the authors provide good scientific support for their conclusions that subjects reporting >5-15 grams/day of total alcohol intake (from about _ to 1 _ of a typical drink), and wine drinkers of 2-7 drinks/week, are at approximately 30% lower risk of developing depression than are abstainers of alcohol.
Comments on this paper were provided by the following members of the International Scientific Forum on Alcohol Research:
Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA
Erik Skovenborg, MD, Scandinavian Medical Alcohol Board, Practitioner, Aarhus, Denmark
Giovanni de Gaetano, MD, PhD, Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, Italy
Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway
David Van Velden, MD, Dept. of Pathology, Stellenbosch University, Stellenbosch, South Africa
R. Curtis Ellison, MD, Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA
Differences between wine and other alcoholic beverages in terms of adverse consequences of alcohol consumption
Dey M, Gmel G, Studer J, Dermota P, Mohler-Kuo M. Beverage preferences and associated drinking patterns, consequences and other substance use behaviours. European Journal of Public Health 2013; advance access; doi:10.1093/eurpub/ckt109
Background: Studies about beverage preferences in a country in which wine drinking is relatively widespread (like Switzerland) are scarce. Therefore, the main aims of the present study were to examine the associations between beverage preferences and drinking patterns, alcohol-related consequences and the use of other substances among Swiss young men.
Methods: The analytical sample consisted of 5399 Swiss men who participated in the Cohort Study on Substance Use Risk Factors (C-SURF) and had been drinking alcohol over the preceding 12 months. Logistic regression analyses were conducted to study the associations between preference for a particular beverage and (i) drinking patterns, (ii) negative alcohol-related consequences and (iii) the (at-risk) use of cigarettes, cannabis and other illicit drugs.
Results: Preference for beer was associated with risky drinking patterns and, comparable with a preference for strong alcohol, with the use of illicit substances (cannabis and other illicit drugs). In contrast, a preference for wine was associated with low-risk alcohol consumption and a reduced likelihood of experiencing at least four negative alcohol-related consequences or of daily cigarette smoking. Furthermore, the likelihood of negative outcomes (alcohol-related consequences; use of other substances) increased among people with risky drinking behaviours, independent of beverage preference.
Conclusions: In our survey, beer preference was associated with risky drinking patterns and illicit drug use. Alcohol polices to prevent large quantities of alcohol consumption, especially of cheaper spirits like beer, should be considered to reduce total alcohol consumption and the negative consequences associated with these beverage types.
The present study was based on questionnaire data related to alcohol intake that were obtained from just over one half of military conscripts from the general population who were invited to participate. Their average age was just over 19 years. “Risky single occasion drinking” (RSOD) was defined as consuming at least six standard drinks (10-12 g of alcohol/drink), and “At risk RSOD” was defined as risky drinking episodes at least once a month. Beverage preference was based on reporting that 2/3rds or more of the total intake of a subject came from one type of beverage. The intake of apertifs, alcopops, beer pops, wine pops, chillers, and coolers were all classified as “other preferences.” Overall, 31.7% preferred beer, 5.4% preferred wine, and 11.5% had “other preferences.”
Only 0.3% of subjects reported an average intake of > 21 drinks/week. Hence, these young subjects were primarily light drinkers or “binge” drinkers.
Many previous studies have shown healthier outcomes associated with the consumption of wine than of other alcoholic beverages. Such beneficial effects are generally attributed both to the polyphenols and other constituents of wine, other than alcohol, as well as to the drinking pattern and more moderate other lifestyle factors of wine consumers.
To some extent, the present study supports such findings, as the risk of most adverse alcohol-related consequences (e.g., blackouts, accidents, unprotected sex, encounters with police) were much less likely among men in whom two-thirds or more of their total alcohol consumption was from wine than from other beverages. Beer drinkers were more frequently binge drinkers. Smoking (both cigarettes and cannabis) and the use of illicit drugs were much less common among wine drinkers than either beer drinkers or those with other preferences. However, more frequent binge drinking, of any beverage, strongly related to an increase in adverse alcohol-related consequences.
Reviewer Finkel commented: “Nothing new here: young men, especially in the company of other young people, engage in risky behaviour more than us more boring beings. Ever shall it be. I agree that the support of this study may help enable more sensible programs and legislation, but it will be difficult to persuade the rule makers that wine should be treated differently from other beverages. (Probably we should focus on treating young brains.)”
Forum member Skovenborg agreed: “Not much to learn from this study with cross-sectional data from a Swiss cohort study. As the authors acknowledge, men with a preference for beer and strong alcohol belong to a particular subculture that demonstrates problematic substance use due to personal characteristics. No causal inferences may be drawn due to lack of longitudinal data.” Skovenborg continued: “I am not sure why the authors suggest an attempt to reduce total alcohol intake in this group of young men, where consumption of more than 21 drinks per week occurred rarely. The essential problem is at risk binge drinking. To curb the binge drinking pattern of this group of young men with a price increase might work, however, even the illegal status of cannabis and other illicit drugs has not been able to stop such drug use.”
Implications of the results of this study for setting alcohol policy: Forum reviewer Ursini had some interesting observations: “The authors suggest that in order to decrease the ‘negative consequences’ of alcohol intake (the reference to the use of cannabis and illicit drugs is straightforward), alcohol policy must aim to prevent, with highest priority, the consumption of the beer just because it is ‘cheap.’ As a matter of fact the same results could be obtained by increasing the price of either beer (possibly welcome in terms of Governmental taxes) or of illicit drugs (but this would be inappropriate and definitely out of the Governmental control). The other option (the most desirable) would be increasing the richness of young people that in this way would be “protected” from the use of illicit drugs, while drinking –in moderation- the most expensive wines and spirits.”
The authors suggest that the data from this study may be useful when planning programs for reducing alcohol misuse. They state specifically that while preventive strategies should attempt to reduce excessive drinking of all types of beverages, “to lessen the additional negative effects of beer and strong alcohol, which are particularly cheap in Switzerland, targeted strategies such as minimum pricing policies for these beverage types should be considered.” In the opinion of Forum members, it is yet to be shown the extent to which such price restructuring would decrease unhealthy drinking practic0es among young people.
Questionnaire-based data on alcohol consumption were collected from more than 5,000 military recruits in Switzerland, who had a mean age of just over 19 years. There were very few drinkers who averaged more than 21 drinks/week, so the emphasis was on the effects of what is usually referred to as “binge drinking,” defined in this study as the consumption of 6 or more typical drinks (a drink containing 10-12 g of alcohol) on a single occasion. The “preference” of one particular type of beverage was based on the subject indicating that it made up more than two-thirds of his total alcohol consumption. The specific type of beverage preferred — beer, wine, or “other beverages” (the latter including apertifs, “pops,” chillers, and coolers) — was related to the pattern of drinking (frequency of binge drinking) and to the reported occurrence of adverse alcohol-related consequences (e.g., blackouts, driving after heavy drinking, missing work due to drinking, accidents, unprotected sex, encounters with police).
The authors report: “Preference for beer was associated with risky drinking patterns and, comparable with a preference for strong alcohol, with the use of illicit substances (cannabis and other illicit drugs). In contrast, a preference for wine was associated with low-risk alcohol consumption and a reduced likelihood of experiencing at least four negative alcohol-related consequences or of daily cigarette smoking.” More frequent binge drinking of any beverage was strongly associated with an increase in adverse alcohol-related consequences.
Forum reviewers thought that the adverse outcomes, especially those related to heavy beer intake, tend to characterize a particular subculture that demonstrates problematic substance use due to personal characteristics of the subjects. The unhealthy outcomes may be a feature more of the cultural habits of the subjects rather than just due to the type of beverage they consume most frequently.
The authors conclude that strategies for preventing problems with alcohol abuse should attempt to reduce excessive drinking of all types of beverages. However, they add: “to lessen the additional negative effects of beer and strong alcohol, which are particularly cheap in Switzerland, targeted strategies such as minimum pricing policies for these beverage types should be considered.” Forum members think that the extent to which such beverage-specific price restructuring would decrease unhealthy drinking practices among young people remains unclear
Comments on the critique of this paper were provided by the following members of the International Scientific Forum on Alcohol Research:
Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA
Erik Skovenborg, MD, Scandinavian Medical Alcohol Board, Practitioner, Aarhus, Denmark
Fulvio Ursini, MD, Dept. of Biological Chemistry, University of Padova, Padova, Italy
Arduino A. Mangoni, PhD, Strategic Professor of Clinical Pharmacology and Senior Consultant in Clinical Pharmacology and Internal Medicine, Department of Clinical Pharmacology, Flinders University, Bedford Park, SA; Australia
R. Curtis Ellison, MD, Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA.