Acta psychiat. scand. (1979)60, 199-213 Department of Clinical Alcohol and Drug Research (Head: Carl-Magnus Zdestrom), Karolinska Hospital, Karolinska Institute, Stockholm, Sweden
Female alcoholics V. MORBIDITY L. DAHLGRENAND C.-M.
IDESTROM
Data from the public health insurance societies regarding 66 f s male alcoholics, hospitalized for the first time for alcoholism at the Department of Alcohol Diseases, Karolinska Hospital, Stockholm, were studied, and the developmental pattern of morbidity was compared with that of 68 male alcoholics fulfilling the same criteria. The observation period was 15 years. The progress of the alcoholism was not reflected in data from the social insurance societies up to the time of the first clinical treatment. However, the morbidity increased in both sexes after the treatment period, with higher disability, severity, and frequency rates, a large number of persons with disability pensions and increasing social stigmatization. The proportion of women granted disability pensions increased to significantly higher values than that of men, and that of women in the general popuIation. The women had significantly fewer registrations in social registers than the men during the whole period. Women and older patients had higher disability rates, more sick-days due to “mental diseases” and a higher severity rate before admission. All differences were equalized in the last part of the study.
Key words: Alcoholism - sex factors - morbidity
- social adjust-
ment. The number of working days lost through illness has increased in Sweden and in 1974 was some 100 million days (Romkn (1976)). Two of the factors influencing absence from work are age and sex (Lokander (1962)). Women generally are more often absent from work due to illness than men, especially in the lower age groups. It is shown that diseases of the respiratory and the musculoskeletal system are the most common causes of absence from work and sick benefit days (Siill (1969), Westrin (1973)). O n closer analysis, however, it will be seen that behind the diagnoses there are often other factors involved, e.g. social problems (Romdn (1976)). Cronholm (1961) has pointed out that doctors have a tendency to exaggerate somatic symptoms at the expense of psychiatric disturbances in medical certificates. Lindgren (1957) and Westrin (1973) showed that medical certificates stating low back ailments can hide the existence of mental trouble and abuse of alcohol. Alcoholism involves an extremely high general morbidity and many somatic complications. Morbidity among male alcoholics has been studied by several 0001-690X/79/070199-15$02.50/0 @ 1979 Munksgaard, Copenhagen
200 Swedish authors. Lindgren (1957) found an increased rate of absence from work due to sickness among male municipal employees subjected to internal disciplinary measures for drunkenness at work. A special study classified the increased morbidity as mental disorders, diseases of the musculoskeletal system, accidents, and to some extent, diseases of the digestive and circulatory system. Lokander (1962) reported an increased absence rate among male employees with alcohol problems. Bjerver (1972) could show an identical disease profile among men who had been submitted to compulsory treatment by the Temperance Board. Berglin & Rosengren (1974) studied alcoholic out-patients and stressed the considerable loss of work productivity caused by these. Information from the public health insurance societies showed high morbidity among alcoholics previously admitted to public institutions for alcoholics (Lundquist (1965), Adrell (196611, hospital departments for alcoholic diseases (Lundquist (1968)) and psychiatric wards (Rorsman (1970)). An increased morbidity rate among alcoholic women is shown by Observer & Maxwell (1959), Pel1 & D’Alonzo (1970) and Asma et al. (1971). A Swedish investigation (Nykterhetsvfirdens rage I och 11, 1967) gives some information about a large number of sick women who, at a given time in 1964, were either examined or treated in accordance with the Temperance Act. Medhus (1974) studied female alcoholics who had been submitted to compulsory treatment by the Temperance Board, and he could show a rising disability rate up to the year preceding intervention. The increase represented mainly the diagnostic categories: accidents and mental disorders. Maxwell (1960) pointed out the importance of observing early symptoms of an alcohol problem in the individual during his working life, these symptoms often being the first signs of the existence of a developing alcoholism. The symptoms are, however, difficult to identify in their early stages. Maxwell enumerated such signs as alcoholic hangover, morning drinking, absence from work and nervousness as initial symptoms. PURPOSE OF THE STUDY The purpose of this study is to elucidate the developmental pattern of morbidity within a group of female alcoholics, hospitalized for the first time for alcoholism. The observation period is totally 15 years - eight years before and six years after the year of the first clinical treatment. The pattern of morbidity is compared with that of a group of men, treated for the &st time and in the same department. MATERIAL AND METHODS Selection of subject groups The material comprised a group of female patients, consecutively hospitalized for alcoholism for the first time during the period 1963-1969 at the Department of Alcoholic Diseases, Karolinska Hospital, Stockhoh. They also fulfilled the following criteria: a) Treated at the department for at least 7 days.
201
Table 1. Age distribution of alcoholic men and women at admission Men
Age
Women
n
%
n
%
21-30 years 3 1 4 0 years 41-50 years 51-60 years
15 16 28 9
22 24 41 13
12 14 25 15
18 21 38 23
Total Mean (s.d.) age
68 100 40.3 (10.1)
66 100 42.1 (10.8)
Table 2. Marital status of alcoholic men and women at admission Marital status
Men
Women
n
%
n
%
Marriedlcohabit Single, never married Divorcedkeparated Widow/widower
29 15 23 1
43 22 34 1
33 15 15 3
50 23 23 4
Total
68
100
66
100
b) Still alive 1 year after the treatment period. Old age pension not to be considered during the observation period. Furthermore, two women who emigrated immediately after discharge from the department were excluded from the study. The patients have been accounted as not available for observation if below the age of 17. After the exclusion of eight persons according to b) and nine according to c) the female patient group consisted of 66 women. The female patients were compared with male patients fulfilling the same criteria. After the exclusion of two men according to b) and four men according to c) the male patient group comprised 68 persons. The Department of Alcoholic Diseases is a specialized clinic, established mainly as a research and education centre but engaging in medical training and ordinary medical activities as well. Admittance to the department usually took place after a note of admission had been received from other departments of the Karolinska Hospital, surrounding hospitals, or from physicians in general practice. Some of the patients were admitted from the psychiatric emergency room in an acute state. The various ways of admission have been accounted for in a previous report (Dahlgren & Myrhed (1977)). Early cases were given preference, i.e. those subjects who had retained their social functions were first admitted. The patients accepted in-patient treatment voluntarily. Only those who fulfilled criteria of established alcohol dependence (i.e. change of alcohol tolerance, “craving”, loss of control, or inability to
C)
202 abstain) were included in the study. After discharge, each patient was offered continued treatment at an out-patient department, either at Karolinska Hospital or in the community. Descriptive data of subjects Ages at the time of admission ranged from 21 to 60 years, mean age 40.3 (s.d. 10.1) and 42.1 (s.d. 10.8) for men and women, respectively (Table 1). As will be seen from Table 2, 43 % of the men and 50 % of the women were married or living with a partner. There was no significant difference in the marital status compared with the total patient material of alcoholic men and women treated at the same department, as accounted for in previous reports (Dahlgren & Myrhed (1977)). Both the men and the women had a relatively.high level of education and about 50 % of both sexes had passed at least a lower certificate examination. At the time of admission about 10 % of the men and 12 % of the women were out of work. In both sexes, those employed were reported to be stable workers, often having held their jobs for many years. All the men and 73 % of the women had worked outside the home at some time during the 8 years preceding the treatment year. The employment status at admission is shown in Table 3. One third of the men were officials (half of them higher-grade), one third were craftsmen, 10 % had service occupations, 10 % were owners of business enterprises and 6 % were unqualified labourers. As regards the women, one third had service occupations (mostly withiin the restaurant branch), one third were occupied as officials (lower-grade), 5 % were creative artists and 3 % were unqualified labourers. Methods After admission, a social investigation was made, including a scan of the data from the official social register, a check with the mental hospital in the district, the acquisition of information from relations and employers, other hospitals, and the police authorities. Since 1st January 1955 all persons resident in Sweden having reached the age of 16 are insured for sickness cash benefit provided their annual income from gainful activity is estimated at a minimum of 1,800 Sw. kr. (in 1965) and 4,500 Sw. kr. (in 1975). The sickness cash benefit is in direct relation to the income. Housewives and men under 67 who are living permanently with their spouse are guaranteed a sickness benefit even though they do not have an annual income from gainful activity. The same rule applies to unmarried insured persons who have children under 16 years of age who are still at home. The authors have had access to the insurance records and related documents concerning the male and female patients for the period 1955 to 1975. The waiting period never exceeded 3 days (National Insurance (1967) and (1972), Public Sickness Funds (1962)). The data studied cover 15 years for each patient, i.e. 8 years before admission (year -8), treatment year (year 0) and 6 years thereafter (year +6).
203 Table 3. Employment at admission Men n
Women %
n
%
21
Officials
high-grade low-grade
5
12 9
18 13
3 14
2 4
3 6
3 6 9
20
29
7
10 3
-
2
3
5
Unqualified labourer
4
6
2
3
Out of work
7
10
8
12
16
24
Service occupations social service and nursing wcupation
shop assistant restaurant personnel Craftsmen Private enterprises owner of a business enterprise
creative artist
Housewives
Class 0 / Disability pension
5
9 13
1
2
2
3
68
100
66
100
-~
Total
The diagnoses recorded by the insurance society were based on the physician’s certificate in cases of benefits paid for a period of more than 7 days, and on a statement from the patient when the sickness period was shorter. More than one diagnosis was listed for 8.2 % of the women’s and 5.3 % of the men’s sickness periods. Only the first diagnosis given was used in this study. The International Statistical Classification of Diseases, Injuries, and Causes of Death (1965,1968) was used for coding the diagnoses. For nominal variables significance tests were made using the common chisquare test for observed frequencies with Yates’ correction. In the case of fewer than 20 observations the Fisher exact z-test was used. As regards the quantitative variables many of them were, as expected, markedly skewed. When both t-test for uncorrelated series and the Mann-Whitney Utest (non-parametric) were applied, however, no dzerences were found in the significance level. This is the reason why, in the present report, only t-test values are presented. Daerences between observed and expected number of disability pensions were tested according to the Poisson distribution function (Pearson (1930)). Degrees of significance were tested at the 5 %, 1 % and 0.1 % level.
204
4
-7
4
4
4
J
-2
-,
0
1 1
+2
tl
*.
15
t6
, .Y.
Fig. 1. The proportion not insured for daily allowance (those in class 0 and those with disability pensions). Year 0 = the year of first clinical treatment.
RESULTS Persons insured f o r daily allowance (housewives and those gainfully employed) The proportion of men insured for daily allowance varied around 95 % up to the time of admission. Subsequently, it decreased slightly and was 91 % at year +6. For the women, the proportion varied approximately 92-95 % up to year 0, after which it decreased to barely 65 %. The difference between the two groups was significant for the last 4 years of observation (Fig. 1). (P < 0.01 for year +3, +4, P < 0.001 for year + 5 , + 6 ) . Women without an income from gainful employment were classified as housewives if they 1) regularly lived with children under 16 years of age or 2) lived with a husband (or equivalent). The proportion of housewives varied about 25-30 % between year -8 and year 0. Thereafter, it decreased steadily and was only 1 % at the end of the observation period. No man could be classified as “husband without earnings”. Persons not insured f o r daily allowance (those in class 0 and those with disability pension) Persons fit for work but without an income who could not be classified as housewives or “husbands without earnings” were placed in class 0. During the 8 years before admission to hospital 3 % of the men and 6 % of the women were placed in class 0. The figure remained unchanged or even decreased as regards the men but rose among the women to 15 % at year +6. No man had a disability pension before the year of admission. Subsequently, the proportion slowly rose to 9 %. No woman had a disability pension at year -8 to -5, 2-3 % had at year -4 to 0. This figure increased during the last 4 years to 19 %.
205
The total percentage of women not insured €or daily allowance increased nearly six times from year 0 (6 %) to year +6 (35 %), reflecting a decrease in the percentage of those gainfully employed and those registered as housewives (Fig. 1). The differences between men and women were significant for the last 4 years of observation (P < 0.001). For the years +1 to + 6 (i.e. after the treatment period) six men and 11 women received a disability pension. When standardization was carried out for age, sex, and time periods, the expected number was found to be 2.7 for the men ( P > 0.05) and 3.0 for the women (P < 0.001). When the total material (men and women) was divided into a younger group (56 persons < 4 0 years of age at admission) and an older group (78 persons > 40 years of age at admission), it was found that fewer younger patients than older were insured for daily allowance during the first 7 years of the obseryation period (significant for the years -8 to -4, P < 0.01). The reason was that a considerable number of young individuals were situated in the 0-class. The differences between the age groups disappeared, however, in the middle of the period. From year + 3 onwards the proportion of insured persons decreased in both age groups. This decrease, however, was most marked in the older patients, as a certain number of individuals received disabiIity pensions. The system for calculation of daily allowance has been changed three times during the observation period, i.e. in 1962, 1966 and 1973, and consequently the figures for the actual allowance are not comparable from year to year. However, the daily allowance classes rose steadily for both sexes and showed no tendency to decrease either at the time of admission or at the end of the observation period. As in the general population, the daily allowance classes of the women were consistently somewhat lower than those of the men.
I1 n
0
+I
Fig. 2. Sickness benefit days per person insured for daily allowance. Year 0 = the year of first clinical treatment.
206
I
Fig. 3. The percentage not sick per year of those insured for daily allowance. Year 0 = the year of first clinical treatment.
Sickness cash benefit days per insured person covered by compulsory health insurance (disability rate) For the years -8 to -4, the disability rate of the women was approximately twice as high as that of the men (about 30 and 15 days per person, respectively). At year -1 it rose for both sexes to the same amount - about 55 days per person - and during the 6 years after the treatment period it was consistently high for both sexes (70-80 days per person) (Fig. 2). The total amount of benefit days per person for the period of 6 years before and 6 years after the treatment year has been calculated. The figures were higher for the women and for the older patients (>40 years of age at admission) in the first period (significant for both age (P< 0.01) and sex (P < 0.05)) but the differences disappeared in the latter half of the observation period. The percentage “not sick” per year of persons covered by compulsory health insurance The percentage of those not sick, among the men and women covered by compulsory health insurance, decreased during the observation period. At year -8 60 % of the men and 56 % of the women were not sick, at year -1 the percentage was about 25 for both sexes. During year + 2 to +6 the proportion “not sick” among the women was consistently 21-24 %, and among the men it rose from 10 % to 28 % (Fig. 3). Sickness periods per person insured for daily allowance (frequency rate) and sickness benefit days per sickness period (severity rate) The frequency rate rose among the men from 0.7 to 2.4 periods per person
207 and among the women from 0.9 to 2.5 over the observation period. During the first half of the observation period, the severity rate varied from 7.7 days (year -8) to 23.9 (year -1) among the men and from 9.7 days to 22.2 among the women. From year + 2 it decreased among the men from 53.7 days (maximal value) to 31.1 (year +6). As regards the women the maximal value was found at year +1 (60.1 days per period), at year +6 it has decreased to 47.8. The total severity rate for a period of 6 years before and 6 years after the treatment year was compared for age and sex. The figures were higher for the women and for the older patients during the first period (significant for both age (P < 0.001) and sex (P< 0.05)) but the differences disappeared in the latter half of the observation period. Disease profile The disability rate was divided into diagnostic categories. Some of these were interesting and were specially studied. Mental disorders. For the women, approximately 15 sickness benefit days per year, per daily allowance insured person, were attributed to the diagnostic category of mental disorders during the first 6 years of observation. For the 2 years before treatment, the number of days rose to 19. At year 0, the treatment year, the number was 80 days, which decreased to 64 days at year +6. As regards the men, they started with 4-5 days at years -8 to -3, with an increase to 10-17 days at years -2 and -1. After the treatment year the number was about 55-60 days with a decrease during the last 2 years to 44 and 26 days. The total amount of benefit days per person under this diagnostic category 6 years before and 6 years after the treatment year has been calculated. The figures were higher for the women and for the older patients in the first period (significant for both age and sex (P< 0.05)), but the differences disappeared in the latter half of the observation period. Accidents, poisonings and violence. For the women, the disability rate for this diagnostic category started at year -8 with 1.2 days per person and increased up to year -1 (17.8 days). After year 0 there was a slow decrease to 1.3 days. The men had about 2.5 days in the first period. The figure rose to 16.6 (maximal value) at year +2 and decreased to 2.6 at the end of the observation period. The total number of benefit days per person in this diagnostic category, 6 years before and 6 years after the treatment year has been calculated. The figures were higher for the men and for the older patients in the first period (significant for both age (P < 0.05) and sex (P < 0.001)) but differences disappeared in the latter half of the observation period. Diseases of the respiratory system, the digestive system and the musculoskeletal system are further diagnostic categories of special interest in alcoholics. No differences were found between the groups, nor any special trend in the morbidity under these diagnostic Categories.
208
Fig. 4. Days per person of hospital treatment. Year 0 = the year of first clinical treatment.
Days per person of hospital treatment
For the first 7 years of the observation period the mean number of days of hospital treatment did not reach 1.0 in either sex group. At year -1 it was 2.5 and 1.0 for men and women, respectively. After the high number of days at year 0 it varied between 3 and 10 among the men and between 5 and 14 among the women (Fig. 4). The mean number of days per person and year of hospital treatment 6 years before admission was, for the men, 0.8 and, for the women, 0.5 and 6 years later 9.1 and 9.5 days, respectively. As regards age groups, the older patients (> 40 years of age at admission) were treated in hospital 0.6 days per person during the former period and 9.1 days in the latter period. The figures relating to the younger patients were 0.9 and 6.4, for the two periods. Data from registers kept by the social welfare committees, the Temperance Boards, the Alcohol Section of the National Tax Board and the police authorities
According to the principles of selection most of the patients were either unknown or known only because of an isolated drunkenness offence, or drunken driving, in social registers, by the Temperance Board and in police registers. At the beginning of the observation period 9 % of the men and 2 % of the women were registered. At admission the figures were 57 % and 14 % for men and women respectively. At year + 6 the figures for the men showed a pronounced increase to 97 %; 76 % of the women were still unknown. The differences were significant from year -7 onwards (Fig. 5). (P < 0.01 in year -7 to -4, P < 0.001 for year -3 onwards). Among the women, before admission, there was one case of drunken driving
209
r
-1
n
I I1 I1 I1 4
.,
4
I
4
1
I
I
0
*I
12
tl
Id
I.
L
+l
+b
I“’
Fig. 5 . Proportion of alcoholic men and women registered in social registers, at the Temperance Boards, or in police registers. Year 0 = the year of first clinical treatment.
and four cases of supervision by the Temperance Board. At year +6 eight women had been placed under supervision and nine women received compulsory treatment by the Temperance Board. Four cases of drunken driving were found. The total number of drunkenness offences was seven before and 35 after the admission (distributed among four and 12 women, respectively). As regards the men there were 13 cases of drunken driving before and 15 after the treatment year. Three men had been placed under supervision but none had received compulsory treatment by the Temperance Board before the admission; two men had been supervised and four had been submitted to compulsory treatment at the end of the observation period. The total number of drunkenness offences was 19 before the admission and 86 during the period year + I - +6 (distributed among nine and 21 men, respectively). One single man was responsible for 27 drunkenness offences during this time. Other crimes, such as theft and fraud, were found in eight cases before and 20 at the end of the observation period.
DISCUSSION The most obvious finding as regards both sex groups is an apparent increase of morbidity during the last part of the observation period, i.e. after the treatment year. The increased morbidity is shown both as a higher disability rate, severity rate and frequency rate, and as a higher number of persons with disability pensions. Data from social and police registers also show an increasing social stigmatization. Medhus (1974) noticed that interventions by the Temperance Board did not make alcoholic women “healthier” but at that point in time broke the unfavourable morbidity trend. The patients in the present study were alcoholics, defined in medical terms rather than in social terms (Bjurulf 14
210 et a(. (1971)) as they were patients in a hospital, and selected by criteria implying retained social function. Evidently this group of alcoholics may develop so advanced abuse and alcohol-related disabilities even before the first clinical treatment, as intervention from other people fails to succeed, that rehabilitation may be impossible. The same trend is shown in a study by Salum (1972). She investigated over 1,000 alcoholic male patients, treated in a hospital, and found more patients without known social problems among the medically very serious cases than among the patients with less advanced medical symptoms. The increased morbidity could also indicate that persons with repeated periods of illness who earlier had no connection with a doctor, as a consequence of medical treatment had greater possibility to obtain a doctor’s certificate. In that case, the short sickness periods would be numerous before the admission, i.e. the patient would make use of his right to report himself ill for a period no longer than a week. The frequency rate for men and women certainly increased, although not very much, and did not exceed 2.5 periods per year before the admission. Also, the severity rate was more than 7 days for both sex groups already at the very beginning of the observation period. It is not likely, though, that establishing contact with a medical centre in itself results in an increased morbidity, as would appear from the data from the social insurance office. Most of the patients developed increasing alcohol problems but managed to compensate and to keep it secret for a long time. When they were forced to seek medical help because of a bad general condition, the compensation could not be retained and several functions were deficient at one time. It seems as if alcoholics, defined principally in medical terms, come for medical treatment too late and that an effective instrument for reaching them in time is still missing. Could the information from the social insurance office be of help in
this? During the last 2 years before admission a discreet increase in the disability rate and a decrease in the number of non-sick persons has been observed. In the women and in the older patients there was also an increased severity rate before the admission. The progress of the alcoholism is definitely not as evident as shown by many others, e.g. Medhus (1974) when writing about Swedish women 4 years before they had undergone compulsory treatment by the Temperance Board. On the contrary, the development of the alcoholism gives the impression that most of the patients “hid” from the social insurance office until the first admission. As regards the women this was often as an emergency case (Dahlgren & Myrhed (1977)) which is reflected in the increase of sick-days due to diagnoses of “accident” in the course of the year before the admission. The disability rate of the general population has increased in Sweden during the observation period and in 1960 was 13.2 days per person. In 1965 it was 15.2 and 16.2, and in 1970, 21.0 and 18.0 for men and women, respectively (National Insurance (1967, 1972), Public Sickness Funds (1962)). Compared with these figures, the men showed a “normal” disability rate up to year -2 while the
211 women had a higher rate each year. Significant differences in disability rate between the sexes are only seen before the admission. One of the most striking daerences between the sex groups was found in the proportion of non-insured persons (i.e. persons in 0-class and those with disability pensions). The proportion of women was greater than that of men throughout the whole observation period, and the difference is highly significant for the last 4 years. The women in our study received disability pensions to a significantly larger extent than women in the general population. This observation could be explained by the greater difficulty for women on the labour market, which leads to widened criteria for a disability pension. The proportion of housewives decreased from 30 % to 1 % during the observation period, possibly implying broken marriages, children being taken into public care, and rehabilitation attempts at work outside the home, as well as new trends and a changing society. The increase of women with disability pensions could also be related to an aggravation of women’s conditions and more advanced alcoholrelated disabilites, shown in the higher disability rate before admission and the tendency to appear as emergency cases. It could also mean, that the criteria in the present study constitute a poor prognosis for the women. Bateman & Petersen (1972) found that for a woman a favourable prognosis tended to be associated with quite different criteria, such as low social status, low educational achievement and low occupational status. This good prognosis may be a result of the fact that women with occupations of low status have deviated less from the traditional female rijle as they often have nursing and housekeeping occupations. Women with occupations of high social status, however, have deviated further from the traditional r61e when acquiring positions involving career and competition. Difference between the sex groups was also seen in the social and police registers. At the beginning of the observation period less than 10 % of both sexes were known in the registers. The proportion of women entered in any of the social registers increased slowly to 24 %, while the increase of men was rapid and continued throughout the whole observation period. During the last year only 13 % of the men had no registrations. Lokander (1962) showed a connection between the number of drunkenness offences and absence from work in a group of middle-aged men. Alcoholic women are said to drink in secret and, to a higher degree than men, to belong to the category of “hidden alcoholics” (Lindbeck (1972)). The women in this study were certainly more clever than the men at keeping their social integrity in spite of a higher morbidity. This is a characteristic of female alcoholics, relevant in the age groups of patients in hospital (Dahlgren (1978)). There are, however, Swedish investigations showing that young schoolgirls have increasing alcohol consumption and a drinking pattern more similar to boys (Nilsson (1977)). Some of them will develop drinking problems. As they have started drinking alcohol earlier in life, show a different drinking pattern, and have different attitudes to alcohol, they will probably display characteristics different from those found in the female alcoholics treated to-day. The different variables of morbidity for two periods of 6 years - before and
212 after the admission - were compared as regards sex and age. Disability rate, sick-days due to the diagnoses of “mental diseases”, and severity rate showed significantly higher values for the women and for the older patients in the former period; in the latter period all differences were equalized. Consequently, the younger men had the highest increase of morbidity. It has earlier been found that young alcoholics have greater problems, differing from those in the middle age group. Rathod et al. (1966) noticed that young problem drinkers (aged 30 or less) showed a poor prognosis when treated together with older alcoholics. When summing up, it is evident that the patients in the present study, though suffering from various symptoms of alcohol abuse for a long time, come to the point when the need for medical treatment is too strong to be ignored. Most of them were “hidden alcoholics” until admission. By being admitted into a hospital they became identified and diagnosed as alcoholics. How this fact may have influenced the further development of the disease, and what kind of intervention could have been made at an earlier stage, are questions to be asked. This problem has earlier been considered by other authors (e.g. Lundin (1976)) i.e. whether medical care and the social welfare service are always of use to the alcoholic patient. REFERENCES Adrell, R . (1966): Klientel och prognosundersokning vid statlig vftrdanstalt for alkoholmissbrukare. Liikartidningen 63, 142. Asma, F.E., R . L . Eggert & R . R . J . Hilker (1971): Long-term experience with rehabilitation of alcoholic employees. J. occup. Med. 13, 581-585. Bateman, N.J., & D . M . Petersen (1972): Factors related to outcome of treatment for hospitalized white male and female alcoholics. J. drug Issues 2, 66-74. Berglin, C.G., & E. Rosengren (1974): Arbetsprestationer och pensionering hos 868 alkoholister. Liikartidningen 38, 3520-3521. Bjerver, K . (1972): An evaluation of compulsive treatment programs for alcoholic patients in Stockholm with particular reference to longitudinal development, epidemiological aspects and patient morbidity. Opusc. med. (Stockh.), Suppl. 25. Bjurulf, P., N . H. Stenby & B. Wistedt (1971): Definitions of alcoholism. Relevance of liver disease and Temperance Board Registrations in Sweden. Quart. J. Stud. Alcohol 32, 393-405. Cronholm, B. (1961): Psykiska och somatiska arbetshinder. Stencil, Stockholm. Dahfgren, L. (1978): Female alcoholics. 111. Development and pattern of problem drinking. Acta psychiat. scand. 57, 325-335. Dahlgren, L., & M . Myrhed (1977): Female alcoholics. I. Ways of admission of the alcoholic patient. A study with special reference to the alcoholic female. Acta psychiat. scand. 56, 39-49. Lindgren, G . (1957):Alkohol och arbete. Svensk Liik.-Tidn. 48, 3613-3637. Lokander,S. (1962): Sick absence in a Swedish company. A sociamedical study. Acta med. scand., Suppl. 377. Lundin, G. (1976): Alkoholmissbrukarna och forsakringskassan. Alkohol Narkotika 718,
35-38. Lundquist, G. (1965): Prognosen och forloppet vid alkoholism. Institutet for maltdryckesforskning No. 13, Stockholm. Lundquist, G. (1968): Studier av forloppet vid alkoholberoende. Institutet for maltdryckesforskning No. 20, Stockholm. Maxwell, M . A . (1960): Early identification of problem drinkers in industry. Quart. J. Stud. Alcohol 21, 655-678.
213 Medhus,A. (1974): Morbidity among female alcoholics. Scand. J. soc. Med. 2, 5-11. Nilsson, T . (1977): Nhgra synpunkter ph den okade kvinnliga alkoholkonsumtionen. I: Kvinnor och alkohol. Rapport frhn Nordiska namnden for alkoholforskning, Stockholm. Observer & M. A. Maxwell (1959): A study of absenteeism, accidents and sickness payments in problem drinkers in one industry. Quart. J. Stud. Alcohol 20, 302-312. Pell, S., & C . A . d'Alonzo (1970): Sickness absenteeism of alcoholics. J. occup. Med. 12, 198. Pearson, K . (1930): Tables for statisticians and biometricians. Part I, 3rd ed. Cambridge University Press, London. Rathod, N . H., E. Gregory, D . Blows & G . H . Thomas (1966): A two year follow-up study of alcoholic patients. Brit. J. Psychiat. 112, 683-692. Romdn, G . (1976): Arbetsvhrd vid psykiska och sociala arbetshinder. Nord. psykiat. T., Suppl. 2. Rorsman, B. (1970): Disability of psychiatric patients. Social Psychiat. 5, 219. SaZum,I. (1972): Delirium tremens and certain other acute sequels of alcohol abuse. Acta psychiat. scand., Suppl. 235. Sall, H. (1969): Andningsorganens sjukdomar vanligast inom RFV-statistik. T. Allm. Forsk., 350-359. Westrin, C . G . (1973): Low back sick-listing. Scand. J. SOC. Med., Suppl. 7. Klassifikation av sjukdomar (1965): (International statistical classification of diseases, injuries and causes of death). Socialstyrelsen, Stockholm. Klassifikation av sjukdomar (1968): (International statistical classification of diseases, injuries and causes of death, 1965 revision adapted for indexing of hospital records and morbidity statistics). Socialstyrelsen, Stockholm. National Insurance 1965 (1967): Official statistics of Sweden. The National Social Insurance Board, Stockholm. National Insurance 1970 (1972): Official statistics of Sweden. The National Social Insurance Board, Stockholm. Nykterhetsvhdens rage (1967): Part I. Klientel och behandlingsresurser. SOU 36, Socialdepartementet, Stockholm. Nykterhetsvlrdens lage (1967): Part 11. Bilagor. SOU 37, Socialdepartementet, Stockholm. Public Sickness Funds 1960 (1962): Official statistics of Sweden. The National Insurance Office, Stockholm. Received February 12, 1979
Lena Dahlgren, M.D. Carl-Magnus Idestrom, M.D. Karolinska Institute Clinic of Alcoholic Diseases S-10401 Stockholm 60 Sweden
Female alcoholics V. MORBIDITY L. DAHLGRENAND C.-M.
IDESTROM
Data from the public health insurance societies regarding 66 f s male alcoholics, hospitalized for the first time for alcoholism at the Department of Alcohol Diseases, Karolinska Hospital, Stockholm, were studied, and the developmental pattern of morbidity was compared with that of 68 male alcoholics fulfilling the same criteria. The observation period was 15 years. The progress of the alcoholism was not reflected in data from the social insurance societies up to the time of the first clinical treatment. However, the morbidity increased in both sexes after the treatment period, with higher disability, severity, and frequency rates, a large number of persons with disability pensions and increasing social stigmatization. The proportion of women granted disability pensions increased to significantly higher values than that of men, and that of women in the general popuIation. The women had significantly fewer registrations in social registers than the men during the whole period. Women and older patients had higher disability rates, more sick-days due to “mental diseases” and a higher severity rate before admission. All differences were equalized in the last part of the study.
Key words: Alcoholism - sex factors - morbidity
- social adjust-
ment. The number of working days lost through illness has increased in Sweden and in 1974 was some 100 million days (Romkn (1976)). Two of the factors influencing absence from work are age and sex (Lokander (1962)). Women generally are more often absent from work due to illness than men, especially in the lower age groups. It is shown that diseases of the respiratory and the musculoskeletal system are the most common causes of absence from work and sick benefit days (Siill (1969), Westrin (1973)). O n closer analysis, however, it will be seen that behind the diagnoses there are often other factors involved, e.g. social problems (Romdn (1976)). Cronholm (1961) has pointed out that doctors have a tendency to exaggerate somatic symptoms at the expense of psychiatric disturbances in medical certificates. Lindgren (1957) and Westrin (1973) showed that medical certificates stating low back ailments can hide the existence of mental trouble and abuse of alcohol. Alcoholism involves an extremely high general morbidity and many somatic complications. Morbidity among male alcoholics has been studied by several 0001-690X/79/070199-15$02.50/0 @ 1979 Munksgaard, Copenhagen
200 Swedish authors. Lindgren (1957) found an increased rate of absence from work due to sickness among male municipal employees subjected to internal disciplinary measures for drunkenness at work. A special study classified the increased morbidity as mental disorders, diseases of the musculoskeletal system, accidents, and to some extent, diseases of the digestive and circulatory system. Lokander (1962) reported an increased absence rate among male employees with alcohol problems. Bjerver (1972) could show an identical disease profile among men who had been submitted to compulsory treatment by the Temperance Board. Berglin & Rosengren (1974) studied alcoholic out-patients and stressed the considerable loss of work productivity caused by these. Information from the public health insurance societies showed high morbidity among alcoholics previously admitted to public institutions for alcoholics (Lundquist (1965), Adrell (196611, hospital departments for alcoholic diseases (Lundquist (1968)) and psychiatric wards (Rorsman (1970)). An increased morbidity rate among alcoholic women is shown by Observer & Maxwell (1959), Pel1 & D’Alonzo (1970) and Asma et al. (1971). A Swedish investigation (Nykterhetsvfirdens rage I och 11, 1967) gives some information about a large number of sick women who, at a given time in 1964, were either examined or treated in accordance with the Temperance Act. Medhus (1974) studied female alcoholics who had been submitted to compulsory treatment by the Temperance Board, and he could show a rising disability rate up to the year preceding intervention. The increase represented mainly the diagnostic categories: accidents and mental disorders. Maxwell (1960) pointed out the importance of observing early symptoms of an alcohol problem in the individual during his working life, these symptoms often being the first signs of the existence of a developing alcoholism. The symptoms are, however, difficult to identify in their early stages. Maxwell enumerated such signs as alcoholic hangover, morning drinking, absence from work and nervousness as initial symptoms. PURPOSE OF THE STUDY The purpose of this study is to elucidate the developmental pattern of morbidity within a group of female alcoholics, hospitalized for the first time for alcoholism. The observation period is totally 15 years - eight years before and six years after the year of the first clinical treatment. The pattern of morbidity is compared with that of a group of men, treated for the &st time and in the same department. MATERIAL AND METHODS Selection of subject groups The material comprised a group of female patients, consecutively hospitalized for alcoholism for the first time during the period 1963-1969 at the Department of Alcoholic Diseases, Karolinska Hospital, Stockhoh. They also fulfilled the following criteria: a) Treated at the department for at least 7 days.
201
Table 1. Age distribution of alcoholic men and women at admission Men
Age
Women
n
%
n
%
21-30 years 3 1 4 0 years 41-50 years 51-60 years
15 16 28 9
22 24 41 13
12 14 25 15
18 21 38 23
Total Mean (s.d.) age
68 100 40.3 (10.1)
66 100 42.1 (10.8)
Table 2. Marital status of alcoholic men and women at admission Marital status
Men
Women
n
%
n
%
Marriedlcohabit Single, never married Divorcedkeparated Widow/widower
29 15 23 1
43 22 34 1
33 15 15 3
50 23 23 4
Total
68
100
66
100
b) Still alive 1 year after the treatment period. Old age pension not to be considered during the observation period. Furthermore, two women who emigrated immediately after discharge from the department were excluded from the study. The patients have been accounted as not available for observation if below the age of 17. After the exclusion of eight persons according to b) and nine according to c) the female patient group consisted of 66 women. The female patients were compared with male patients fulfilling the same criteria. After the exclusion of two men according to b) and four men according to c) the male patient group comprised 68 persons. The Department of Alcoholic Diseases is a specialized clinic, established mainly as a research and education centre but engaging in medical training and ordinary medical activities as well. Admittance to the department usually took place after a note of admission had been received from other departments of the Karolinska Hospital, surrounding hospitals, or from physicians in general practice. Some of the patients were admitted from the psychiatric emergency room in an acute state. The various ways of admission have been accounted for in a previous report (Dahlgren & Myrhed (1977)). Early cases were given preference, i.e. those subjects who had retained their social functions were first admitted. The patients accepted in-patient treatment voluntarily. Only those who fulfilled criteria of established alcohol dependence (i.e. change of alcohol tolerance, “craving”, loss of control, or inability to
C)
202 abstain) were included in the study. After discharge, each patient was offered continued treatment at an out-patient department, either at Karolinska Hospital or in the community. Descriptive data of subjects Ages at the time of admission ranged from 21 to 60 years, mean age 40.3 (s.d. 10.1) and 42.1 (s.d. 10.8) for men and women, respectively (Table 1). As will be seen from Table 2, 43 % of the men and 50 % of the women were married or living with a partner. There was no significant difference in the marital status compared with the total patient material of alcoholic men and women treated at the same department, as accounted for in previous reports (Dahlgren & Myrhed (1977)). Both the men and the women had a relatively.high level of education and about 50 % of both sexes had passed at least a lower certificate examination. At the time of admission about 10 % of the men and 12 % of the women were out of work. In both sexes, those employed were reported to be stable workers, often having held their jobs for many years. All the men and 73 % of the women had worked outside the home at some time during the 8 years preceding the treatment year. The employment status at admission is shown in Table 3. One third of the men were officials (half of them higher-grade), one third were craftsmen, 10 % had service occupations, 10 % were owners of business enterprises and 6 % were unqualified labourers. As regards the women, one third had service occupations (mostly withiin the restaurant branch), one third were occupied as officials (lower-grade), 5 % were creative artists and 3 % were unqualified labourers. Methods After admission, a social investigation was made, including a scan of the data from the official social register, a check with the mental hospital in the district, the acquisition of information from relations and employers, other hospitals, and the police authorities. Since 1st January 1955 all persons resident in Sweden having reached the age of 16 are insured for sickness cash benefit provided their annual income from gainful activity is estimated at a minimum of 1,800 Sw. kr. (in 1965) and 4,500 Sw. kr. (in 1975). The sickness cash benefit is in direct relation to the income. Housewives and men under 67 who are living permanently with their spouse are guaranteed a sickness benefit even though they do not have an annual income from gainful activity. The same rule applies to unmarried insured persons who have children under 16 years of age who are still at home. The authors have had access to the insurance records and related documents concerning the male and female patients for the period 1955 to 1975. The waiting period never exceeded 3 days (National Insurance (1967) and (1972), Public Sickness Funds (1962)). The data studied cover 15 years for each patient, i.e. 8 years before admission (year -8), treatment year (year 0) and 6 years thereafter (year +6).
203 Table 3. Employment at admission Men n
Women %
n
%
21
Officials
high-grade low-grade
5
12 9
18 13
3 14
2 4
3 6
3 6 9
20
29
7
10 3
-
2
3
5
Unqualified labourer
4
6
2
3
Out of work
7
10
8
12
16
24
Service occupations social service and nursing wcupation
shop assistant restaurant personnel Craftsmen Private enterprises owner of a business enterprise
creative artist
Housewives
Class 0 / Disability pension
5
9 13
1
2
2
3
68
100
66
100
-~
Total
The diagnoses recorded by the insurance society were based on the physician’s certificate in cases of benefits paid for a period of more than 7 days, and on a statement from the patient when the sickness period was shorter. More than one diagnosis was listed for 8.2 % of the women’s and 5.3 % of the men’s sickness periods. Only the first diagnosis given was used in this study. The International Statistical Classification of Diseases, Injuries, and Causes of Death (1965,1968) was used for coding the diagnoses. For nominal variables significance tests were made using the common chisquare test for observed frequencies with Yates’ correction. In the case of fewer than 20 observations the Fisher exact z-test was used. As regards the quantitative variables many of them were, as expected, markedly skewed. When both t-test for uncorrelated series and the Mann-Whitney Utest (non-parametric) were applied, however, no dzerences were found in the significance level. This is the reason why, in the present report, only t-test values are presented. Daerences between observed and expected number of disability pensions were tested according to the Poisson distribution function (Pearson (1930)). Degrees of significance were tested at the 5 %, 1 % and 0.1 % level.
204
4
-7
4
4
4
J
-2
-,
0
1 1
+2
tl
*.
15
t6
, .Y.
Fig. 1. The proportion not insured for daily allowance (those in class 0 and those with disability pensions). Year 0 = the year of first clinical treatment.
RESULTS Persons insured f o r daily allowance (housewives and those gainfully employed) The proportion of men insured for daily allowance varied around 95 % up to the time of admission. Subsequently, it decreased slightly and was 91 % at year +6. For the women, the proportion varied approximately 92-95 % up to year 0, after which it decreased to barely 65 %. The difference between the two groups was significant for the last 4 years of observation (Fig. 1). (P < 0.01 for year +3, +4, P < 0.001 for year + 5 , + 6 ) . Women without an income from gainful employment were classified as housewives if they 1) regularly lived with children under 16 years of age or 2) lived with a husband (or equivalent). The proportion of housewives varied about 25-30 % between year -8 and year 0. Thereafter, it decreased steadily and was only 1 % at the end of the observation period. No man could be classified as “husband without earnings”. Persons not insured f o r daily allowance (those in class 0 and those with disability pension) Persons fit for work but without an income who could not be classified as housewives or “husbands without earnings” were placed in class 0. During the 8 years before admission to hospital 3 % of the men and 6 % of the women were placed in class 0. The figure remained unchanged or even decreased as regards the men but rose among the women to 15 % at year +6. No man had a disability pension before the year of admission. Subsequently, the proportion slowly rose to 9 %. No woman had a disability pension at year -8 to -5, 2-3 % had at year -4 to 0. This figure increased during the last 4 years to 19 %.
205
The total percentage of women not insured €or daily allowance increased nearly six times from year 0 (6 %) to year +6 (35 %), reflecting a decrease in the percentage of those gainfully employed and those registered as housewives (Fig. 1). The differences between men and women were significant for the last 4 years of observation (P < 0.001). For the years +1 to + 6 (i.e. after the treatment period) six men and 11 women received a disability pension. When standardization was carried out for age, sex, and time periods, the expected number was found to be 2.7 for the men ( P > 0.05) and 3.0 for the women (P < 0.001). When the total material (men and women) was divided into a younger group (56 persons < 4 0 years of age at admission) and an older group (78 persons > 40 years of age at admission), it was found that fewer younger patients than older were insured for daily allowance during the first 7 years of the obseryation period (significant for the years -8 to -4, P < 0.01). The reason was that a considerable number of young individuals were situated in the 0-class. The differences between the age groups disappeared, however, in the middle of the period. From year + 3 onwards the proportion of insured persons decreased in both age groups. This decrease, however, was most marked in the older patients, as a certain number of individuals received disabiIity pensions. The system for calculation of daily allowance has been changed three times during the observation period, i.e. in 1962, 1966 and 1973, and consequently the figures for the actual allowance are not comparable from year to year. However, the daily allowance classes rose steadily for both sexes and showed no tendency to decrease either at the time of admission or at the end of the observation period. As in the general population, the daily allowance classes of the women were consistently somewhat lower than those of the men.
I1 n
0
+I
Fig. 2. Sickness benefit days per person insured for daily allowance. Year 0 = the year of first clinical treatment.
206
I
Fig. 3. The percentage not sick per year of those insured for daily allowance. Year 0 = the year of first clinical treatment.
Sickness cash benefit days per insured person covered by compulsory health insurance (disability rate) For the years -8 to -4, the disability rate of the women was approximately twice as high as that of the men (about 30 and 15 days per person, respectively). At year -1 it rose for both sexes to the same amount - about 55 days per person - and during the 6 years after the treatment period it was consistently high for both sexes (70-80 days per person) (Fig. 2). The total amount of benefit days per person for the period of 6 years before and 6 years after the treatment year has been calculated. The figures were higher for the women and for the older patients (>40 years of age at admission) in the first period (significant for both age (P< 0.01) and sex (P < 0.05)) but the differences disappeared in the latter half of the observation period. The percentage “not sick” per year of persons covered by compulsory health insurance The percentage of those not sick, among the men and women covered by compulsory health insurance, decreased during the observation period. At year -8 60 % of the men and 56 % of the women were not sick, at year -1 the percentage was about 25 for both sexes. During year + 2 to +6 the proportion “not sick” among the women was consistently 21-24 %, and among the men it rose from 10 % to 28 % (Fig. 3). Sickness periods per person insured for daily allowance (frequency rate) and sickness benefit days per sickness period (severity rate) The frequency rate rose among the men from 0.7 to 2.4 periods per person
207 and among the women from 0.9 to 2.5 over the observation period. During the first half of the observation period, the severity rate varied from 7.7 days (year -8) to 23.9 (year -1) among the men and from 9.7 days to 22.2 among the women. From year + 2 it decreased among the men from 53.7 days (maximal value) to 31.1 (year +6). As regards the women the maximal value was found at year +1 (60.1 days per period), at year +6 it has decreased to 47.8. The total severity rate for a period of 6 years before and 6 years after the treatment year was compared for age and sex. The figures were higher for the women and for the older patients during the first period (significant for both age (P < 0.001) and sex (P< 0.05)) but the differences disappeared in the latter half of the observation period. Disease profile The disability rate was divided into diagnostic categories. Some of these were interesting and were specially studied. Mental disorders. For the women, approximately 15 sickness benefit days per year, per daily allowance insured person, were attributed to the diagnostic category of mental disorders during the first 6 years of observation. For the 2 years before treatment, the number of days rose to 19. At year 0, the treatment year, the number was 80 days, which decreased to 64 days at year +6. As regards the men, they started with 4-5 days at years -8 to -3, with an increase to 10-17 days at years -2 and -1. After the treatment year the number was about 55-60 days with a decrease during the last 2 years to 44 and 26 days. The total amount of benefit days per person under this diagnostic category 6 years before and 6 years after the treatment year has been calculated. The figures were higher for the women and for the older patients in the first period (significant for both age and sex (P< 0.05)), but the differences disappeared in the latter half of the observation period. Accidents, poisonings and violence. For the women, the disability rate for this diagnostic category started at year -8 with 1.2 days per person and increased up to year -1 (17.8 days). After year 0 there was a slow decrease to 1.3 days. The men had about 2.5 days in the first period. The figure rose to 16.6 (maximal value) at year +2 and decreased to 2.6 at the end of the observation period. The total number of benefit days per person in this diagnostic category, 6 years before and 6 years after the treatment year has been calculated. The figures were higher for the men and for the older patients in the first period (significant for both age (P < 0.05) and sex (P < 0.001)) but differences disappeared in the latter half of the observation period. Diseases of the respiratory system, the digestive system and the musculoskeletal system are further diagnostic categories of special interest in alcoholics. No differences were found between the groups, nor any special trend in the morbidity under these diagnostic Categories.
208
Fig. 4. Days per person of hospital treatment. Year 0 = the year of first clinical treatment.
Days per person of hospital treatment
For the first 7 years of the observation period the mean number of days of hospital treatment did not reach 1.0 in either sex group. At year -1 it was 2.5 and 1.0 for men and women, respectively. After the high number of days at year 0 it varied between 3 and 10 among the men and between 5 and 14 among the women (Fig. 4). The mean number of days per person and year of hospital treatment 6 years before admission was, for the men, 0.8 and, for the women, 0.5 and 6 years later 9.1 and 9.5 days, respectively. As regards age groups, the older patients (> 40 years of age at admission) were treated in hospital 0.6 days per person during the former period and 9.1 days in the latter period. The figures relating to the younger patients were 0.9 and 6.4, for the two periods. Data from registers kept by the social welfare committees, the Temperance Boards, the Alcohol Section of the National Tax Board and the police authorities
According to the principles of selection most of the patients were either unknown or known only because of an isolated drunkenness offence, or drunken driving, in social registers, by the Temperance Board and in police registers. At the beginning of the observation period 9 % of the men and 2 % of the women were registered. At admission the figures were 57 % and 14 % for men and women respectively. At year + 6 the figures for the men showed a pronounced increase to 97 %; 76 % of the women were still unknown. The differences were significant from year -7 onwards (Fig. 5). (P < 0.01 in year -7 to -4, P < 0.001 for year -3 onwards). Among the women, before admission, there was one case of drunken driving
209
r
-1
n
I I1 I1 I1 4
.,
4
I
4
1
I
I
0
*I
12
tl
Id
I.
L
+l
+b
I“’
Fig. 5 . Proportion of alcoholic men and women registered in social registers, at the Temperance Boards, or in police registers. Year 0 = the year of first clinical treatment.
and four cases of supervision by the Temperance Board. At year +6 eight women had been placed under supervision and nine women received compulsory treatment by the Temperance Board. Four cases of drunken driving were found. The total number of drunkenness offences was seven before and 35 after the admission (distributed among four and 12 women, respectively). As regards the men there were 13 cases of drunken driving before and 15 after the treatment year. Three men had been placed under supervision but none had received compulsory treatment by the Temperance Board before the admission; two men had been supervised and four had been submitted to compulsory treatment at the end of the observation period. The total number of drunkenness offences was 19 before the admission and 86 during the period year + I - +6 (distributed among nine and 21 men, respectively). One single man was responsible for 27 drunkenness offences during this time. Other crimes, such as theft and fraud, were found in eight cases before and 20 at the end of the observation period.
DISCUSSION The most obvious finding as regards both sex groups is an apparent increase of morbidity during the last part of the observation period, i.e. after the treatment year. The increased morbidity is shown both as a higher disability rate, severity rate and frequency rate, and as a higher number of persons with disability pensions. Data from social and police registers also show an increasing social stigmatization. Medhus (1974) noticed that interventions by the Temperance Board did not make alcoholic women “healthier” but at that point in time broke the unfavourable morbidity trend. The patients in the present study were alcoholics, defined in medical terms rather than in social terms (Bjurulf 14
210 et a(. (1971)) as they were patients in a hospital, and selected by criteria implying retained social function. Evidently this group of alcoholics may develop so advanced abuse and alcohol-related disabilities even before the first clinical treatment, as intervention from other people fails to succeed, that rehabilitation may be impossible. The same trend is shown in a study by Salum (1972). She investigated over 1,000 alcoholic male patients, treated in a hospital, and found more patients without known social problems among the medically very serious cases than among the patients with less advanced medical symptoms. The increased morbidity could also indicate that persons with repeated periods of illness who earlier had no connection with a doctor, as a consequence of medical treatment had greater possibility to obtain a doctor’s certificate. In that case, the short sickness periods would be numerous before the admission, i.e. the patient would make use of his right to report himself ill for a period no longer than a week. The frequency rate for men and women certainly increased, although not very much, and did not exceed 2.5 periods per year before the admission. Also, the severity rate was more than 7 days for both sex groups already at the very beginning of the observation period. It is not likely, though, that establishing contact with a medical centre in itself results in an increased morbidity, as would appear from the data from the social insurance office. Most of the patients developed increasing alcohol problems but managed to compensate and to keep it secret for a long time. When they were forced to seek medical help because of a bad general condition, the compensation could not be retained and several functions were deficient at one time. It seems as if alcoholics, defined principally in medical terms, come for medical treatment too late and that an effective instrument for reaching them in time is still missing. Could the information from the social insurance office be of help in
this? During the last 2 years before admission a discreet increase in the disability rate and a decrease in the number of non-sick persons has been observed. In the women and in the older patients there was also an increased severity rate before the admission. The progress of the alcoholism is definitely not as evident as shown by many others, e.g. Medhus (1974) when writing about Swedish women 4 years before they had undergone compulsory treatment by the Temperance Board. On the contrary, the development of the alcoholism gives the impression that most of the patients “hid” from the social insurance office until the first admission. As regards the women this was often as an emergency case (Dahlgren & Myrhed (1977)) which is reflected in the increase of sick-days due to diagnoses of “accident” in the course of the year before the admission. The disability rate of the general population has increased in Sweden during the observation period and in 1960 was 13.2 days per person. In 1965 it was 15.2 and 16.2, and in 1970, 21.0 and 18.0 for men and women, respectively (National Insurance (1967, 1972), Public Sickness Funds (1962)). Compared with these figures, the men showed a “normal” disability rate up to year -2 while the
211 women had a higher rate each year. Significant differences in disability rate between the sexes are only seen before the admission. One of the most striking daerences between the sex groups was found in the proportion of non-insured persons (i.e. persons in 0-class and those with disability pensions). The proportion of women was greater than that of men throughout the whole observation period, and the difference is highly significant for the last 4 years. The women in our study received disability pensions to a significantly larger extent than women in the general population. This observation could be explained by the greater difficulty for women on the labour market, which leads to widened criteria for a disability pension. The proportion of housewives decreased from 30 % to 1 % during the observation period, possibly implying broken marriages, children being taken into public care, and rehabilitation attempts at work outside the home, as well as new trends and a changing society. The increase of women with disability pensions could also be related to an aggravation of women’s conditions and more advanced alcoholrelated disabilites, shown in the higher disability rate before admission and the tendency to appear as emergency cases. It could also mean, that the criteria in the present study constitute a poor prognosis for the women. Bateman & Petersen (1972) found that for a woman a favourable prognosis tended to be associated with quite different criteria, such as low social status, low educational achievement and low occupational status. This good prognosis may be a result of the fact that women with occupations of low status have deviated less from the traditional female rijle as they often have nursing and housekeeping occupations. Women with occupations of high social status, however, have deviated further from the traditional r61e when acquiring positions involving career and competition. Difference between the sex groups was also seen in the social and police registers. At the beginning of the observation period less than 10 % of both sexes were known in the registers. The proportion of women entered in any of the social registers increased slowly to 24 %, while the increase of men was rapid and continued throughout the whole observation period. During the last year only 13 % of the men had no registrations. Lokander (1962) showed a connection between the number of drunkenness offences and absence from work in a group of middle-aged men. Alcoholic women are said to drink in secret and, to a higher degree than men, to belong to the category of “hidden alcoholics” (Lindbeck (1972)). The women in this study were certainly more clever than the men at keeping their social integrity in spite of a higher morbidity. This is a characteristic of female alcoholics, relevant in the age groups of patients in hospital (Dahlgren (1978)). There are, however, Swedish investigations showing that young schoolgirls have increasing alcohol consumption and a drinking pattern more similar to boys (Nilsson (1977)). Some of them will develop drinking problems. As they have started drinking alcohol earlier in life, show a different drinking pattern, and have different attitudes to alcohol, they will probably display characteristics different from those found in the female alcoholics treated to-day. The different variables of morbidity for two periods of 6 years - before and
212 after the admission - were compared as regards sex and age. Disability rate, sick-days due to the diagnoses of “mental diseases”, and severity rate showed significantly higher values for the women and for the older patients in the former period; in the latter period all differences were equalized. Consequently, the younger men had the highest increase of morbidity. It has earlier been found that young alcoholics have greater problems, differing from those in the middle age group. Rathod et al. (1966) noticed that young problem drinkers (aged 30 or less) showed a poor prognosis when treated together with older alcoholics. When summing up, it is evident that the patients in the present study, though suffering from various symptoms of alcohol abuse for a long time, come to the point when the need for medical treatment is too strong to be ignored. Most of them were “hidden alcoholics” until admission. By being admitted into a hospital they became identified and diagnosed as alcoholics. How this fact may have influenced the further development of the disease, and what kind of intervention could have been made at an earlier stage, are questions to be asked. This problem has earlier been considered by other authors (e.g. Lundin (1976)) i.e. whether medical care and the social welfare service are always of use to the alcoholic patient. REFERENCES Adrell, R . (1966): Klientel och prognosundersokning vid statlig vftrdanstalt for alkoholmissbrukare. Liikartidningen 63, 142. Asma, F.E., R . L . Eggert & R . R . J . Hilker (1971): Long-term experience with rehabilitation of alcoholic employees. J. occup. Med. 13, 581-585. Bateman, N.J., & D . M . Petersen (1972): Factors related to outcome of treatment for hospitalized white male and female alcoholics. J. drug Issues 2, 66-74. Berglin, C.G., & E. Rosengren (1974): Arbetsprestationer och pensionering hos 868 alkoholister. Liikartidningen 38, 3520-3521. Bjerver, K . (1972): An evaluation of compulsive treatment programs for alcoholic patients in Stockholm with particular reference to longitudinal development, epidemiological aspects and patient morbidity. Opusc. med. (Stockh.), Suppl. 25. Bjurulf, P., N . H. Stenby & B. Wistedt (1971): Definitions of alcoholism. Relevance of liver disease and Temperance Board Registrations in Sweden. Quart. J. Stud. Alcohol 32, 393-405. Cronholm, B. (1961): Psykiska och somatiska arbetshinder. Stencil, Stockholm. Dahfgren, L. (1978): Female alcoholics. 111. Development and pattern of problem drinking. Acta psychiat. scand. 57, 325-335. Dahlgren, L., & M . Myrhed (1977): Female alcoholics. I. Ways of admission of the alcoholic patient. A study with special reference to the alcoholic female. Acta psychiat. scand. 56, 39-49. Lindgren, G . (1957):Alkohol och arbete. Svensk Liik.-Tidn. 48, 3613-3637. Lokander,S. (1962): Sick absence in a Swedish company. A sociamedical study. Acta med. scand., Suppl. 377. Lundin, G. (1976): Alkoholmissbrukarna och forsakringskassan. Alkohol Narkotika 718,
35-38. Lundquist, G. (1965): Prognosen och forloppet vid alkoholism. Institutet for maltdryckesforskning No. 13, Stockholm. Lundquist, G. (1968): Studier av forloppet vid alkoholberoende. Institutet for maltdryckesforskning No. 20, Stockholm. Maxwell, M . A . (1960): Early identification of problem drinkers in industry. Quart. J. Stud. Alcohol 21, 655-678.
213 Medhus,A. (1974): Morbidity among female alcoholics. Scand. J. soc. Med. 2, 5-11. Nilsson, T . (1977): Nhgra synpunkter ph den okade kvinnliga alkoholkonsumtionen. I: Kvinnor och alkohol. Rapport frhn Nordiska namnden for alkoholforskning, Stockholm. Observer & M. A. Maxwell (1959): A study of absenteeism, accidents and sickness payments in problem drinkers in one industry. Quart. J. Stud. Alcohol 20, 302-312. Pell, S., & C . A . d'Alonzo (1970): Sickness absenteeism of alcoholics. J. occup. Med. 12, 198. Pearson, K . (1930): Tables for statisticians and biometricians. Part I, 3rd ed. Cambridge University Press, London. Rathod, N . H., E. Gregory, D . Blows & G . H . Thomas (1966): A two year follow-up study of alcoholic patients. Brit. J. Psychiat. 112, 683-692. Romdn, G . (1976): Arbetsvhrd vid psykiska och sociala arbetshinder. Nord. psykiat. T., Suppl. 2. Rorsman, B. (1970): Disability of psychiatric patients. Social Psychiat. 5, 219. SaZum,I. (1972): Delirium tremens and certain other acute sequels of alcohol abuse. Acta psychiat. scand., Suppl. 235. Sall, H. (1969): Andningsorganens sjukdomar vanligast inom RFV-statistik. T. Allm. Forsk., 350-359. Westrin, C . G . (1973): Low back sick-listing. Scand. J. SOC. Med., Suppl. 7. Klassifikation av sjukdomar (1965): (International statistical classification of diseases, injuries and causes of death). Socialstyrelsen, Stockholm. Klassifikation av sjukdomar (1968): (International statistical classification of diseases, injuries and causes of death, 1965 revision adapted for indexing of hospital records and morbidity statistics). Socialstyrelsen, Stockholm. National Insurance 1965 (1967): Official statistics of Sweden. The National Social Insurance Board, Stockholm. National Insurance 1970 (1972): Official statistics of Sweden. The National Social Insurance Board, Stockholm. Nykterhetsvhdens rage (1967): Part I. Klientel och behandlingsresurser. SOU 36, Socialdepartementet, Stockholm. Nykterhetsvlrdens lage (1967): Part 11. Bilagor. SOU 37, Socialdepartementet, Stockholm. Public Sickness Funds 1960 (1962): Official statistics of Sweden. The National Insurance Office, Stockholm. Received February 12, 1979
Lena Dahlgren, M.D. Carl-Magnus Idestrom, M.D. Karolinska Institute Clinic of Alcoholic Diseases S-10401 Stockholm 60 Sweden
