Resumen:

En México la dinámica y magnitud del consumo de bebidas embriagantes se conoce desde el último tercio del siglo pasado gracias a las encuestas en hogares; éstas perfilaron el uso de alcohol como una de las principales tareas de la salud pública a escala nacional debido no sólo a sus consecuencias, sino también al deterioro en las diferentes áreas de funcionamiento de la vida cotidiana del sujeto. Desde entonces sobresalen indicadores como la tasa de abstinencia, la proporción de población consumidora de alcohol, la edad de inicio de ingesta y los problemas asociados al consumo.

Como problema de salud pública, el consumo de alcohol requiere llevar a cabo acciones determinantes que hagan frente a esta problemática, para ello toda acción que se genere es prácticamente imposible si se carece de instrumentos que establezcan un diagnóstico diferencial entre el consumo excesivo y la dependencia del alcohol.

En México resultan ser insuficientes las investigaciones que den cuenta de la validez de instrumentos diagnósticos sobre la dependencia del etanol. La Escala de Dependencia del Alcohol (EDA) considera esta dependencia como un continuum, con diferentes niveles, en función del grado de afectación en cada una de las áreas de funcionamiento del individuo. Estudios previos reportan la validez de la EDA como un instrumento de diagnóstico y de tamizaje en otros países.

El presente artículo pretende mostrar la validez de la EDA en los habitantes de la Ciudad de México. Se empleó un diseño de casos y controles comparados 1:1 por edad y estado civil.

A través de un muestreo intencionado por cuota se eligieron 240 sujetos de sexo masculino con edades entre 18 y 50 años.

Los casos fueron 120 sujetos que acudieron voluntariamente a solicitar tratamiento al Centro de Ayuda al Alcohólico y sus Familiares (CAAF), quienes cubrieron los criterios de dependencia del etanol según el DSM-IV, presentaron ingesta de alcohol en el último mes y contaban con primaria completa.

Los controles fueron 120 sujetos residentes de zonas aledañas al CAAF y no cubrieron los criterios de dependencia al etanol.

Se consideró como estándar de oro los Criterios Diagnósticos del DSM-IV para los análisis de sensibilidad, especificidad y valores predictivos; además se señala la estructura factorial y consistencia interna de la escala.

Los datos sociodemográficos indican que el promedio de edad de los sujetos fue de 34 años, poco más de la mitad se encontraba con pareja al momento del estudio.

Entre los casos, 86% cubrió de 6 a 7 criterios de dependencia del etanol del DSM-IV; el nivel de dependencia predominante fue moderado con 37% a diferencia de los controles, quienes en su mayoría no mostraron evidencia de dependencia.

Las pruebas de heterogeneidad mostraron diferencias estadísticamente significativas en los niveles de dependencia entre los casos y los controles.

La EDA presentó una consistencia interna global de 0.96 a partir del Coeficiente de Confiabilidad de Cronbach, mayor al nivel de consistencia que se reportó en estudios previos.

Se analizaron diferentes puntos de corte y el más adecuado para detectar una dependencia clínicamente significativa fue de ocho puntos, con sensibilidad de 96%, y especificidad de 98%. Estos hallazgos demuestran que la EDA es un instrumento clínico y de tamizaje adecuado para emplearse en habitantes de la Ciudad de México.

Palabras clave: Escala de dependencia del alcohol; dependencia del alcohol; estructura factorial; sensibilidad

Summary:

The dynamic and scope of the consumption of alcoholic beverages, in Mexico, have been known by household surveys, since the last third of the last century.

Nowadays those surveys describe alcohol use as one of the main public health tasks nationwide, due not only to its consequences but also to the damage on the different areas of individual's everyday life.

A number of indicators have been highlighted by the first survey on 1988, such as teetotalism rates, the alcohol consumers proportion, age of first use, and problems associated with alcohol consumption.

As a public health problem, alcohol consumption represents high costs to health institutions because of the problems related to the consumption. So, it requires undertaking certain actions that would be deal with this problem on primary and structural attention, as well as in the individual susceptibility as prevention, or attention levels, diagnosis and treatment.

All actions to face this problem are practically impossible in the absence of instruments to establish differential diagnosis between heavy drinking and alcohol dependence.

Along the study of alcoholism, have been distinguished two issues to establish differential diagnosis. First is a traditional version of dependence diagnosis by DSM criterions, defined as disadaptative pattern of alcohol consumption that produces significant malaise, expressed trough one year long.

The second diagnosis issue quantifies the individual differences of physical, psychological and social damage degrees, caused by the alcohol consumption. From this, appears the motion of Multiple Alcoholism Syndrome.

From this last point of view, The Alcohol Use Inventary by Skinner, Horn and Wanberg (1983), is compose by 147 items self administrated, clusted in 24 scales. Time latter, as of many researches done by this research group, aroused The Multiple-syndrome Alcohol Model as The Alcohol Use Inventary simplified version, used as a useful differential diagnosis questionnaire in alcoholics.

There for, last version has been done many researches that agree on characterize the alcohol use inventory as screening questionnaire useful to detect problematic drinking to implement primary intervention. Those authors suggest the use of this questionnaire at different stages and populations, with different cut points.

Antecedent's use of the questionnaire in Mexico, by Ayala et al., made the adapted version, however, researches seems to be not enough to know the validity of diagnostic instruments on ethanol dependence.

The Alcohol Dependence Scale (ADS) consider the dependence as a continuum of four levels, depending on the damage degree associated with alcohol consumption, on the different areas of physical, intellectual, social and psychiatric functioning. In the questionnaire 1 is the minimum cut point for dependence diagnostic and 48 as the highest point, this rank lets differentiate with respect to low dependence, moderate dependence, substantial dependence and severe dependence.

This article pretends to diffuse the EDS’s validity on inhabitants in Mexico City. As methodology, a case design and 1:1 paired controls were used by age and marital status.

Through a not intentioned sampling by quotas were selected 240 men of 18 to 50 years old.

The cases group was integrated by 120 individuals that voluntarily sought treatment at the Center of Assistance for the Alcoholic and Relatives (CAAF) from June, 1998 to June, 2000.

All cases comply with DSM-IV alcohol dependence criterion; they reported the last consumption at one month before the beginning of the research and with basic school as scholar level.

In the control group were 120 volunteers that request treatment to CAAF from June, 1998 to June, 2000. They did not comply with alcohol dependence criterion.

As gold standard, was considered the DSM-IV criteria to sensibility, specificity and predictive values; the factorial structure and internal consistency of the scale are indicated.

Socio-demographic data indicated 34 years old as sample average, just over the half had a partner at the time of the study; the predominant education level was secondary school (35%).

In the cases the 86% covered 6 to 7 criteria for ethanol dependence in the DSM-IV; the predominant dependence level was moderate at 37%, while 53% of the control group had no evidence of dependence. The heterogeneity test showed significant statistics differences on dependence levels in cases and controls (t=23, df=238 and p=0.00).

The ADS displays overall internal consistency of 0.96, based on the Cronbach Reliability Coefficient, a higher level of consistency than that reported in previous studies.

With a factorial analysis by varimax rotation and maximum likelihood extraction, revealed the presence of three factors with 56.5% of variance explained: intoxication (48.3%), abstinence (5.6%) and delirium tremens.

In the application manual, the authors specify 13/14 as values to use the DAS as a diagnosis questionnaire, and 9 for a screening instrument. While other authors suggest less cut points 13/14 to 2/3 to reduce the false-negative; however, on Mexico City inhabitants, such cut points were inappropriate.

The most suitable cut point to detect a significant dependence on clinical was at 8 points, with 96% sensitivity, 98% specificity and a 94% likelihood of making correct diagnoses.

These findings show that DAS is a suitable screening instrument for using on Mexico City inhabitants.

We suggest including items to evaluate social area or any other scale to complement the ADS.

Key words: Alcohol dependence scale; alcohol dependence; factorial structure; sensitivity