Alcohol Dependence in Women: Difficulty of Its Assessment in General Practice

Abstract

Background:

In France, women represent approximately 20% of alcohol-dependent subjects. Although general practitioners (GPs) are often these women's first medical contact, GPs may be reluctant to probe for alcohol dependence.

Method:

In this context, in 1996 and 2006 we conducted a cross-sectional survey using self-completion postal questionnaires sent to all GPs in a French département (administrative area), with the aim to explore and to compare after a ten-year time lapse, expectations and relational difficulties in managing alcohol dependence in women.

Results:

A total of 300 GPs returned the questionnaire for the two data collection times. According to the GPs, comparing 1996 and 2006, there was less embarrassment among female patient to talk about alcohol consumption and a lesser tendency to break off medical care (33.7% vs. 47.3%, p < 0.001, and 13.3% vs. 23.0%, p = 0.002, respectively). In 2006, more GPs considered they were well informed about specialized care in alcohol dependence than in 1996 (76.8% vs. 59.9%, p < 0.0001), and more often reported referring their female patients to specialized centers (73.0% vs. 52.7%, p < 0.0001), rather than medical or psychiatric wards. Young GPs, aged under 40, seem rather to have had difficulty using the managed care network than lacking medical knowledge related to female alcohol dependence.

Conclusions:

The results suggest that over ten years there has been a decrease in the tendency among women to deny their alcohol dependence, and that they more readily accept specific care. In the same period, GPs have benefited from better information about specialized management.

Introduction

Despite a 50% decrease in the mean quantity of alcohol ingested per inhabitant, per year, during the last 40 years in France, alcohol-related dependence still remains a major public health concern.^1
–3 In France, alcohol consumption is the third highest among European countries, with 5 million alcohol abusers and 2 to 3 million alcohol-dependent patients.¹

Alcohol dependence in women is characterized by different clinical features: first, a later age at onset than in men,^4,5 a more pejorative course, and greater sensitivity to somatic complications.^6,7 For example, women more rapidly develop alcohol-related complications such as hepatitis, arterial hypertension, or gastric-intestinal bleeding.⁸ Some studies also show a significant correlation between alcohol dependence and breast cancer,⁹ and excessive alcohol use during pregnancy involves a significant risk of abortion and abnormal fetus development.¹⁰ Second, alcohol intake is more often dissimulated, solitary, and occurs in the evenings, while in men consumption is more convivial, with a more socially favorable acceptance.¹¹

Although the global prevalence of excessive alcohol use has diminished over the past twenty years, alcohol-related dependence has increased in young women under 40. Although women represent approximately 20% (600,000) of alcohol-dependent subjects, and although 25% of women with alcohol dependence are known to the healthcare system, female alcohol dependence has not been as thoroughly investigated as among male subjects.^12,13

In primary care, one study estimated that 16% of patients consulting their GP had an alcohol problem, 27% of men and 5% of women, and a quarter of these patients had not been previously identified.¹⁴ Women, especially young and university educated, are less likely to receive intervention, despite being identified as at risk.¹⁵ Because GPs are often the first medical contact for these women, it seems essential to improve their ability to detect alcohol dependence. A GP's commitment or ability may be hampered by individual factors such as knowledge, skill, attitudes, beliefs, and expectations. These factors can be improved by education and training.¹⁶ Initial medical training content varies among French universities, with the number of teaching hours devoted to issues of alcohol dependence varying from none in certain universities to 8 hours in others.¹⁷

Among the several studies performed in primary care on female alcohol dependence, there are few data on the specific assessment and management of alcohol problems in women.¹⁸ In 1996 and 2006 we thus conducted the first study in a sample of French GPs, aiming to explore expectations and relational difficulties in managing alcohol dependence in women.

Materials and Methods

The Champagne-Ardenne is an administrative region made up of four départements in northeast France. The Marne is the main administrative division of this region and also the world-famous champagne producing area.

A cross-sectional survey, in which self-completion postal questionnaires were sent to all identifiable GPs in the Marne, was conducted in two stages, in November 1996 and in September 2006. The total number of GPs identified in the Marne was 500 in 1996 and 517 in 2006, for a total number of inhabitants of more than 550,000. For each data collection, the questionnaire was sent by mail to all identified GPs. The questionnaire contained questions on doctor-patient relations, and on the knowledge and use of specialized management care for women with alcohol dependence. The data from the present study were seen as particularly sensitive, and doctors were asked to return questionnaires anonymously.

The standardized questionnaire comprised the following questions:

Have you ever felt embarrassed in asking female patients about drinking? (yes/no)

What kind of reactions among your female patients suffering from an alcohol dependence have you had to deal with when asking about drinking? (patient embarrassment, denial, minimization, refusal to receive medical care, and breaking off of medical care)

Do your female patients suffering from an alcohol-related problem often directly ask you for medical care? (yes/no)

What kind of complications (somatic, social, familial) can lead you to look for alcohol dependence? (patient's demand, partner's demand, alcohol-related somatic complications, psychiatric comorbidity, social complications, family troubles)

In case of alcohol dependence, what kind of appropriate care focused on alcohol do you usually propose? (outpatient treatment by the GP or by a psychiatrist, as center specialized in alcohol dependence treatment, rehabilitation center, hospitalization in a medical ward or in a psychiatric ward)

Are you well informed about management of alcohol problems? (yes/no)

Do you feel the need for a partnership between primary care and treatment centers specialized in managing alcohol dependence? (yes/no)

In addition, we asked in which area the GP practiced. The Champagne-Ardenne area was split into 6 zones corresponding to the six main towns. Among these six, Chalons and Reims were considered urban areas and the four others (Epernay, Sézanne, Sainte-Ménehould, Vitry-le-François) were considered rural areas. Gender and age data were introduced in the 2006 version of the questionnaire.

Statistical Methods

Responses were coded on Excel, and Systat 7.0 software was used for statistical analyses. T-tests were used to evidence differences in responses to the different questions between 1996 and 2006. Chi-square tests were used to compare all items of the questionnaire between 1996 and 2006. The level of significance was less than 0.05.

Results

Among the 500 questionnaires sent out in 1996 and the 517 sent out in 2006, a total of 300 were completed and returned for the two periods. The response rate was thus 60% in 1996 and 58% in 2006. In 1996, among the 300 questionnaires received, 274 were fully completed (91.3%), and 26 (8.7%) only partially. In 2006, there were 286 fully completed questionnaires (95.3%), and 14 partially completed (4.7%). Regarding the geographic localization, in 1996 we had 89 (29.7%) GPs working in a rural area, and 211 (70.3%) in an urban area; in 2006 we had 83 (27.7%) GPs working in a rural area, and 217 (72.3%) in an urban area. There was no significant difference in the rural vs. urban localization of GPs between 1996 and 2006 (χ² = 0.29, p = 0.58).

In 2006, among the GPs who answered the questionnaire, 87 (29.4%) were women with a mean age of 45.2 ± 7.4 years, and 212 (70.6%) were men with a mean age of 50.7 ± 8.5 years (t = 5.31, p < 0.001). One GP did not specify gender.

The GPs' answers to each question according to year of data collection are presented in Table 1.

Table 1.

Answers to the Questionnaire According to Year of Survey

Questions	1996 (n = 300)		2006 (n = 300)
	n	%	n	%	χ²	p
Have you ever felt embarrassed to ask female patients about alcohol dependence?
Yes	86	29.0	82	27.5
No	211	71.0	217	72.5	0.17	0.67
What kinds of reactions among your female patients suffering from an alcohol dependence have you dealt with when asking about the problem?
Patient felt embarrassed	142	47.3	101	33.7	11.62	<0.001
Denial	210	70.0	189	63.0	3.29	0.07
Minimisation	71	23.7	83	27.7	1.25	0.26
Refusal to receive medical care	92	30.7	78	26.0	1.60	0.20
Breaking off the medical care	69	23.0	40	13.3	9.43	0.002
Do your female patients suffering from an alcohol-related problem often directly ask you for medical care?
Yes	57	19.3	57	19.4
No	239	80.7	237	80.6	0.002	0.97
What kinds of complications (somatic, social, familial) can lead you to detect an alcohol dependence?
Patient's demand	87	29.0	116	38.7	6.26	0.01
Partner's demand	145	48.3	130	43.3	1.51	0.21
Alcohol-related somatic complications	211	70.3	215	71.7	0.13	0.72
Psychiatric comorbidity	143	47.7	130	43.3	1.13	0.28
Social complications	83	27.7	100	33.3	2.27	0.13
Family troubles	154	51.3	162	54.0	0.43	0.51
In the case of alcohol dependence, what kinds of appropriate care focusing on treatment do you usually propose?
Outpatient treatment by the GP	232	77.3	217	72.3	1.99	0.16
Outpatient treatment by a psychiatrist	93	31.0	101	33.7	0.48	0.48
Establishment specialized in alcohol dependence treatment	158	52.7	219	73.0	–	<0.0001
Rehabilitation center	13	4.3	14	4.7	0.04	0.84
Hospitalization in a medical ward	70	23.3	48	16.0	5.1	0.02
Hospitalization in a psychiatric ward	38	12.7	19	6.3	6.99	0.008
Are you well informed about management care of alcohol dependence?
Yes	164	59.9	229	76.8
No	110	40.1	69	23.2	19.19	<0.0001
Do you feel the need for a partnership between primary care and centers specializing in the management of alcohol dependence?
Yes	236	82.5	217	75.9
No	50	17.5	69	24.1	3.83	0.05

In 2006, among the 82 GPs who felt embarrassed to ask female patients about alcohol dependence, there was no significant difference according to GP gender, with 55 (18.5%) men and 26 (8.7%) women (χ² = 0.45, p = 0.5) responding that they were.

Between 1996 and 2006, our data showed a decrease in the reporting of female patients feeling embarrassed (47.3% vs. 33.7%, p < 0.001) and breaking off medical care (23.0% vs. 13.3%, p = 0.002) when issues of alcohol dependence were broached.

Direct and spontaneous demands from the women patients were more frequently reported in 2006 than in 1996 (38.7% vs. 29.0%, respectively, p = 0.01). Nevertheless, the GPs seemed equally embarrassed to broach an alcohol dependence problem in 2006 and in 1996 (27.5% vs. 29.0%, respectively, χ² = 0.17, p = 0.67).

In 2006, GPs more often reported referring patients to centers specialized in alcohol dependence treatment than in 1996 (73.0% vs. 52.7%, respectively, p < 0.0001) and less frequently to a medical ward (16.0% vs. 23.3%, p = 0.02) or to a psychiatric ward (6.3% vs. 12.7%, respectively, p = 0.008).

In 2006, 76.8% of the GPs reported they were well informed about management of alcohol dependence, against 59.9% in 1996 (p < 0.0001).

In 2006, 24.1% of GPs did not feel the need for a partnership between primary care and centers specializing in the management of alcohol dependence, vs. 17.5% in 1996 (p = 0.05).

Nevertheless, in 2006 75.9% still reported feeling the need for partnership; the proportion is significantly less for those over 40 years (χ² = 4.35, p = 0.037). In 2006, regardless of age, the GPs reported a benefit from this partnership: 48 (87.3%) vs. 7 (12.7%) for those under 40 years, and 168 (74.0%) vs. 59 (26.0%) for those over 40 years.

Discussion

Our objective was to explore the failure to probe for alcohol dependence in women in primary care, leading to delays in establishment of specific care.¹ Indeed, it has been previously shown that GPs may experience difficulties in dealing with alcohol dependence in their female patients and in orienting them to a suitable medical care program.^14,19 In 1996, we sent a questionnaire by mail to all active general practitioners practicing in the Marne département, aiming to explore their knowledge, behavior, and expectations regarding the management of alcohol dependence in women.

The main strength of the design of our study was the fact that ten years after the first mailing, the same questionnaire was readdressed, to practicing GPs in the same geographical area. We had no information about the rate of physicians who have participated in both studies.

For 1996 and 2006, the response rates reflected a persistent interest from GPs regarding the management of alcohol dependence in their female patients. In 2006, 29% of responders were women. This is slightly lower than the 37% female practitioners response reported for 2005 by the French Medical Association among GPs overall in the Marne.²⁰

In ten years, although the response to most items in the questionnaire remained the same, GPs' knowledge and expectations have changed. In 2006, the GPs more widely reported being informed about specialized management care than in 1996. In 2006, GPs more often reported referring their patients to rehabilitation centers rather than to nonspecialized medical or psychiatric departments. These results could be interpreted as the consequence of the establishment, in 2001, of a social and health network. This network, known as ADDICA (ADDIction Champagne-Ardenne), was formed to provide better management of addictions. ADDICA comprises GPs, specialists in the treatment of addictions, nurses, psychologists, pharmacists, occupational health workers, social workers, and specialised agents (éducateurs), and today has 450 members. The aim of the network is the structured managed care of patients presenting one or several addictions to psychoactive substances, consumption of psychoactive substances and/or anorexia or bulimia, and/or difficulty in accessing managed care because of poverty. Another mission of ADDICA is to provide training. ADDICA has a Web site, with 50.000 visitors a year. This Web site is secure, available only for health professionals, and provides medical consensus on illicit drugs, alcohol and tobacco (20 medical experts are available online), medical files (1,600 patients agreed to have their medical record on the Web site), and online inquiry.

Thus, a better knowledge of the management of alcohol dependence may explain why in 2006 fewer GPs felt the need for a partnership with centers specialized in managing alcohol dependence. In 2006, younger GPs considered that information regarding orientation for specialized managed care of alcohol dependence should be associated with the development of a personalized network which would provide additional, informal contacts among the members of the network. Older GPs have already developed a personalized network, because the numerous years of practice have enabled these additional informal contacts.

Regarding patient orientation and the GPs' personal knowledge of specialized centers, there is no significant difference that correlates with the GPs' age. GPs under 40 seem to be more involved in alcohol networks and partnership with specialized centers. There is no difference related to GPs' gender on any issue regarding orientation, knowledge of specialized centers, alcohol dependence networks, or partnerships.

Concerning the doctor-patient relationship, a recent study²¹ aimed to understand everyday alcohol-related clinical practices in comparison with another analysis conducted 20 years earlier.²² The conclusion was that detecting and managing alcohol dependence was still a difficult issue, many GPs reporting reluctance in initially asking patients about a dependency on alcohol. Concerning difficulties about reaching a diagnosis, GPs reported coping with many different definitions of alcohol dependence. Concerning difficulties in confronting the patient, the GPs reported that when patients did raise this subject, they were often motivated by life crises, or had been brought in by other family members. Most often it was the GP who had decided to initiate any discussion. Concerning partnerships, all GPs raised some degree of concern about hospital or specialist services and, when faced with focused difficult relationships, focused on services with, and across, voluntary, social, and community sectors as well as specialized hospitals.²¹

Several studies have focused on physicians' attitudes to and relationships with patients having an alcohol dependence.^16,6 Physicians' failure to identify and deal with this specific problem has been ascribed to factors such as a lack of appropriate medical education²³ or negative experiences of working with such patients.²⁴ Another explanation is that, most of the time, GPs can spend only a limited amount of time with their patients.

Regarding patient reaction when the GPs asked their patients about alcohol use, in the present study, comparing results in 2006 to those from 1996, GPs less frequently reported that patients found it an embarrassing situation, and they less frequently reported a tendency for the patient to break off medical care. A “minimization” of alcohol dependence was reported to be relatively frequent, but denial was the most frequent patient reaction reported by the GPs. Denial significantly diminished over the 10-year interval according to the GP report, alongside an increasing minimization reaction among patients.

This tendency might explain the lesser degree of embarrassment reported by GPs for their female patients. This reaction may be due to better information among the general population in urban areas, increased organization of alcohol dependence care, more developed and accessible specialized centers, an improved social network, and less isolation and stigmatization resulting from female alcohol dependence.

The media coverage of alcohol-related problems as a disease, and information to GPs regarding specialized managed care, may have significantly improved the quality of care management of women suffering from alcohol dependence. As a consequence of these developments, there is less value-based judgment and less discrimination. This improved attitude allows women to talk more easily about their alcohol consumption. Denial is disappearing, and minimization is increasing. There is no difference between the GPs under 40 years and those over 40 concerning their embarrassment in broaching alcohol dependence with female patients. A GP's age appears to play no role in patient embarrassment, in denial or minimization, in treatment or medical care refusal, or in patient demand.

The difficulty for a GP to ask a woman about alcohol dependence did not change over the ten years of followup. In 1996, as in 2006, some GPs had difficulty asking women about alcohol use. Nevertheless, even these GPs admit that women with alcohol dependencies have changed in their reactions about the medical care involved, and it seems that they feel less embarrassed and less liable to refuse medical treatment. Denial seems less frequent, and the minimization of alcohol consumption seems more frequent than ten years ago. Can it be said that today alcoholic-dependent women more easily agree to talk about it, but cannot accept the gravity of the problems?

Somatic complications and family difficulties are the most frequent opportunities used by GPs in 1996, as well as in 2006, to bring up alcohol dependence. About 18% of patients consulting a GP have a risk of an alcohol-related physical problem, but only half of them are identified as such by the GP.^25,26

Patients with addictions or substance misuse more frequently consult their GP,²⁷ but “addiction” as the stated reason is very rare. Alcohol dependence as the stated reason for consultation occurs in only 1.6% of medical consults, despite a very high level of patient confidence in their GP.²⁸ It has been reported that among patients who consult their physicians during a year, 90% considered that GPs can legitimately ask them about their alcohol dependence; nevertheless, only 9% actually had a discussion about it.²⁹

The bias represented by the selection of GPs more aware of the topic should be taken into account in interpreting the results. However, the same bias would have been present at both data collection dates, allowing relevant comparisons. Another limitation of the 2006 study is the lack of information regarding age and gender of the participating physicians in 1996.

Conclusions

Between 1996 and 2006, GPs reported that among female patients there was a decrease in feeling embarrassed and breaking off medical care when the subject of alcohol dependence was raised. An addition, denial significantly diminished alongside increasing minimization of the problem. These differences are probably due to better information among the general population in urban areas, increased organization of alcohol dependence care, more developed and accessible specialized centers, an improved social network, and less isolation and stigmatization resulting from female alcohol dependence.

In ten years, GPs' knowledge and expectations have changed. In 2006, the GPs reported that they were better informed about specialized management care than in 1996 and more often referred their patients to specialized treatment centers.

The results also suggest that over ten years the tendency among women to deny their alcohol dependence has decreased, and that they more easily accept specific care. At the same time, GPs have benefited from better information about specialized management.

Footnotes

Disclaimer

The authors have no conflict of interest to report.

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