Lifetime Diagnosis Of Alcohol Dependence Research Articles

Residual Effects: Young Adult Diagnostic Drinking Predicts Late-Life Health Outcomes.

This study examined the residual effects of young adult diagnostic drinking on health outcomes four decades later in late life. Results were differentiated by drinking status during midlife. A subsample of Vietnam Era Twin Registry members, all of whom had a lifetime diagnosis of alcohol dependence, was grouped according to life span drinking patterns as assessed by the Lifetime Drinking History interview in 2001. Those drinking at diagnostic levels (endorsing three or more alcohol dependence symptoms) before age 30 were then grouped based on their midlife drinking status (i.e., drinking at diagnostic levels vs. at minimal [nonsymptomatic] levels throughout midlife). Linear (or logistic) regression models were used to examine the association between life span drinking patterns and health outcomes in late life (about age 64). Those who drank at diagnostic levels in young adulthood and in midlife exhibited significant health liabilities on every late-life health measure; those who drank at diagnostic levels for 5 or more years in young adulthood but drank only at minimal levels or not at all in midlife still exhibited similar liabilities on most late-life health measures. Only those individuals who drank diagnostically for less than 5 years in young adulthood displayed normal levels of late-life health. This study identified residual effects resulting from persistent young adult diagnostic drinking (5 or more years) that resulted in negative health outcomes in late life even after decades of remission. There is a distal but surprisingly strong association between persistent early life diagnostic drinking and late-life morbidity.

Alcohol Consumption and Inpatient Health Service Utilization in a Cohort of Patients With Alcohol Dependence After 20 Years of Follow-up.

To examine the association between drinking levels and inpatient health service utilization in people with a lifetime diagnosis of alcohol dependence. A longitudinal prospective study was conducted in a cohort of patients with alcohol dependence who had undergone treatment in 1987. Current results refer to the association between drinking patterns at 20-year follow-up and subsequent inpatient health service utilization. At 20 years after baseline, 530 of 850 patients were alive with administrative data available. Follow-up interview was conducted on 378 patients. There were 88 refusals and 64 could not be traced. Three categories of alcohol consumption were established (abstainers, moderate drinkers and heavy drinkers) depending on the pattern of alcohol use during the last year prior to the evaluation. Health service utilization was based on official statistics, including admissions to general, rehabilitation and psychiatric hospitals. The time period analysed was 5 years after the assessment of drinking patterns. Admission rates were lowest for abstainers compared to people with moderate and heavy drinking. With respect to hospital days, heavy drinking was associated with significantly higher adjusted rates than both abstainers and moderate drinkers. Alcohol-related diagnoses in hospital admissions were more frequent for both moderate and heavy drinkers. Abstinence and moderate alcohol consumption were both associated with lower hospitalization in people with a lifetime diagnosis of alcohol dependence. Thus, not only abstinence-oriented treatment strategies but also those to reduce alcohol intake would reduce inpatient hospitalizations. Abstention and reduced drinking in lifetime alcohol-dependent patients were associated with lower health care utilization compared to heavy drinking. Alcohol treatment strategies for alcohol-dependent patients have a positive impact on the reduction in health care utilization. An increase in treatment rate for alcohol use disorders will consequently have marked population health improvements.

Predictors of heavy drinking after liver transplantation for alcoholic liver disease in Denmark (1990–2013): a nationwide study with competing risks analyses

Objective. Heavy drinking following liver transplantation decreases survival. Little is known of predictors of heavy drinking, which should guide clinicians identifying patients at high risk of return to heavy drinking after transplantation. Material and methods. We calculated the cumulative incidence of heavy drinking among patients transplanted for alcoholic liver disease in Denmark 1990–2013. We then analyzed pre-transplant demographic and psychiatric characteristics as predictors of post-transplant heavy drinking. Information was obtained from medical records, from nationwide registries and by interview. Results. Among 156 liver-transplanted patients, the cumulative incidence of heavy drinking was 18%, 24% and 27% after 5, 10 and 15 years post-transplant. In univariate analyses of pre-transplant predictors of heavy drinking after transplantation, younger age (p < 0.001), being retired (p = 0.007), anxiety (p = 0.04), personality disorder (p = 0.05) and no lifetime diagnosis of alcohol dependence (p = 0.03) were associated with heavy drinking after transplantation. Smoking (p = 0.06) tended to be associated, whereas depression (p = 0.7) or being married was not (p = 0.7). In the multivariate analysis, only younger age (p = 0.03), being retired (p = 0.007) and no lifetime diagnosis of alcohol dependence (p = 0.003) remained significant predictors. Heavy drinking after transplantation decreased survival beyond 5 years post-transplant (p = 0.004). Conclusions.There is a high incidence of heavy drinking after liver transplantation for alcoholic cirrhosis in Denmark. Younger age, being retired and no lifetime diagnosis of alcohol dependence were predictors of heavy drinking after transplantation.

Personality traits of problem gamblers with and without alcohol dependence

IntroductionA large proportion of individuals with gambling disorder also present with a history of alcohol dependence, but few studies have directly examined the relationship between these two conditions. This study's primary and secondary aims were to 1) examine the relationship of personality traits to co-occurring lifetime (current/past) alcohol dependence status, while 2) accounting for differences in gambling characteristics and co-occurring psychiatric disorders among problem/pathological gamblers recruited from the community. MethodsProblem/pathological gamblers (N=150) completed measures of personality traits and gambling characteristics (e.g., gambling severity, gambling involvement, delayed discounting of monetary rewards), and were clinically interviewed for co-occurring psychiatric disorders. ResultsA co-occurring lifetime diagnosis of alcohol dependence (n=61, 40.7%) was associated with lower personality scores for Control, Well-Being, Achievement, Traditionalism, and Harm Avoidance, as well as higher scores for Alienation (Tellegen & Waller, 1994) in bivariate analyses. Problem/pathological gamblers with lifetime alcohol dependence reported greater lifetime gambling severity, greater past-year gambling involvement, steeper delayed discounting, and a greater likelihood of current and lifetime substance dependence, lifetime antisocial personality disorder, and current unipolar mood disorders. Multivariate analyses indicated that lower Control, Traditionalism, and Well-Being and a co-occurring lifetime substance dependence diagnosis best accounted for a co-occurring lifetime alcohol dependence diagnosis in problem/pathological gamblers. ConclusionsProblem/pathological gamblers with co-occurring lifetime alcohol dependence demonstrate addictive behavior across multiple domains and report a personality style characterized by hopelessness, impaired control, and resistance to externally-motivated treatment approaches. Implications for the treatment of these complex cases are discussed.

Startle response to unpredictable threat in comorbid panic disorder and alcohol dependence

BackgroundAlthough the adverse consequences of comorbid panic disorder (PD) and alcohol dependence (AD) are well-established, relatively little is known about the mechanisms underlying their co-occurrence. Several researchers have postulated that alcohol's ability to dampen response to unpredictable threat may be an important motivational factor in comorbid PD and AD. To date, no research has examined these processes using a clinical sample and it is unclear whether individuals with PD and AD evidence different reactivity to unpredictable threat relative to individuals with PD-only. MethodsThe aim of the current study was to examine differences in aversive responding during predictable and unpredictable threat-of-shock in three groups of individuals with: (1) current PD and remitted AD (PD and AD), (2) current PD but no lifetime diagnosis of AD (PD-only), and (3) no lifetime diagnoses of PD or AD (controls). Aversive responding was assessed using a well-established electromyography (EMG) startle paradigm. ResultsResults indicated that PD and AD individuals evidenced greater startle potentiation during unpredictable (but not predictable) threat relative to controls and PD-only individuals (who did not differ). ConclusionsThese findings suggest that heightened reactivity to unpredictable threat may be an important process in PD and AD comorbidity and a possible key motivational factor underlying engagement in alcohol use.

Genetic and Environmental Influences on the Relationship Between Mastery and Alcohol Dependence

Sense of mastery, a personal resource, is likely to have an inverse association with alcohol dependence. Previous evidence, however, is sparse. In addition, the extent to which an association is due to genetic or environmental factors is unknown. Data were from 3,983 male twins and 2,630 female twins who had ever used alcohol, interviewed in the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders. Mastery was measured by a 6-item scale. Lifetime diagnosis of alcohol dependence was based on DSM-IV criteria assessed in a structured diagnostic interview. Univariate analyses modeled the relative contributions of genetic and environmental factors to mastery and alcohol dependence using Mx software. Bivariate Cholesky models were fit to the mastery and alcohol dependence raw data. In the best-fitting model of mastery, genetic factors accounted for about 33% of the observed variance. Nonshared environmental factors, including random measurement error, accounted for the remaining 67%. Fifty-six percent of the variance in liability to alcohol dependence was genetic, and the other 44% was explained by the nonshared environment. The phenotypic polychoric correlation between mastery and alcohol dependence of -0.18 was primarily (67% in the best-fitting model) explained by genes common to both low mastery and alcohol dependence; the rest was explained by nonshared environmental factors. The findings indicate that genetic risk for alcohol dependence overlaps with genetic factors that influence sense of mastery. Key challenges for future research are to identify the genes that influence mastery and alcohol dependence, as well as the environmental pathways by which they come to be linked.

Heritability of alcohol dependence is similar in women and men

Question: How do genetic and environmental factors influence alcohol dependence in women? People: 13 595 female twins and 10 524 male twins aged 20–47 years, born in Sweden between 1959...

Comparison of treated and untreated alcohol dependence in a nationwide sample of Korean adults

We examined factors associated with lifetime treatment of alcohol dependence in a nationwide sample of Korean adults. Of the 6510 respondents, aged 18–64, who participated in the Korean Epidemiologic Catchment Area study, we analyzed 458 who had a lifetime diagnosis of alcohol dependence. Lay interviewers administered a diagnostic assessment, based on the Korean version of the Composite International Diagnostic Interview, to each of the respondents. Of the 458 respondents with a lifetime diagnosis of alcohol dependence, 55 (12.0%) had been treated for psychiatric problems. Treated alcohol-dependent respondents were less likely to have a stable, dyadic relationship or a full-time job. In addition, they were more likely to have experienced alcohol withdrawal symptoms, given up important activities because of alcohol use, and continued alcohol use despite knowing they had an alcohol-associated physical or psychological problem and were less likely to have spent a great deal of time obtaining or drinking alcohol or recovering from its effects. Treated individuals were also more likely to have comorbid mood disorders, especially major depressive disorder, or comorbid anxiety disorders, especially post-traumatic stress disorder, social phobia, or obsessive–compulsive disorder. Alcohol-dependent persons significantly underuse mental health services. Patterns of alcohol use and comorbid psychiatric disorders, as well as socio-demographic factors, affected treatment-seeking by alcohol-dependent individuals in Korea.

N4 component responses to pre-pulse startle stimuli in young adults: Relationship to alcohol dependence

Both physiological and behavioral studies provide evidence to suggest that deficits in frontal cortical control circuits may contribute to the risk for developing alcohol dependence. Event-related potential (ERP) and eye blink responses to startle and short delay prepulse-plus-startle stimuli, and psychiatric diagnoses were investigated in young adult (age 18–30 years) men ( n = 135) and women ( n = 205) Mexican Americans. Women displayed a significant increase in the amplitude of the eye blink response to both the startle and pre-pulse-plus-startle stimuli. None of the psychiatric diagnoses were associated with differences in eye blink responses. ERP responses to the startle and prepulse-plus startle stimuli included a negative polarity wave at approximately 400 ms that was of the highest amplitude in the frontal leads (N4S). Women were found to have significantly higher amplitude N4S responses than men. Participants with alcohol dependence demonstrated significantly less inhibition and more facilitation of the N4S component by the pre-pulse stimuli. This finding was not associated with a diagnosis of: any other drug dependence disorder (including nicotine), anxiety or affective disorder, or conduct/antisocial personality disorder. The present study suggests that gender and a lifetime diagnosis of alcohol dependence may selectively contribute to this frontal late wave electrophysiological response to prepulse-plus-startle stimuli.

Prevalence and Correlates of Withdrawal‐Related Insomnia among Adults with Alcohol Dependence: Results from a National Survey

Insomnia during acute alcohol withdrawal (AWD) as well as persisting insomnia during postacute withdrawal is associated with relapse. Rates of insomnia in clinical samples of alcohol-dependent patients range from 36% to 91%, but the prevalence of AWD-related insomnia in the general population is unknown. The purpose of this study was to describe the prevalence of insomnia as a symptom of acute AWD and its correlates in a general population of alcohol-dependent individuals. Data were analyzed from the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions, which sampled 43,093 adults. The prevalence of AWD-related insomnia among individuals with a lifetime diagnosis of alcohol dependence was 31.7%, which ranked fourth among the eight listed DSM-IV withdrawal symptoms. Among individuals who met lifetime criteria for both alcohol dependence and AWD, the prevalence of insomnia was approximately 50%. Lifetime diagnoses of major depression and drug use disorders were significant correlates of AWD-related insomnia in multivariate analyses. A less than 1-year duration of the heaviest drinking period as well as the onset of alcohol dependence between ages 18 and 27 were negatively associated with AWD-related insomnia. AWD-related insomnia is a common symptom among alcohol-dependent adults in the general population and is related to lifetime co-occurring diagnoses, age at onset of alcohol dependence, and duration of heaviest drinking period. Its prevalence in the general population provides a representative base rate against which to compare the widely varying rates reported in clinical populations. Because of its relatively frequent prevalence and association with relapse, assessment and treatment of AWD-related insomnia should be routinely considered in clinical settings.

EEG alpha phenotypes: linkage analyses and relation to alcohol dependence in an American Indian community study.

BackgroundEvidence for a high degree of heritability of EEG alpha phenotypes has been demonstrated in twin and family studies in a number of populations. However, information on linkage of this phenotype to specific chromosome locations is still limited. This study's aims were to map loci linked to EEG alpha phenotypes and to determine if there was overlap with loci previously mapped for alcohol dependence in an American Indian community at high risk for substance dependence.MethodsEach participant gave a blood sample and completed a structured diagnostic interview using the Semi Structured Assessment for the Genetics of Alcoholism. Bipolar EEGs were collected and spectral power determined in the alpha (7.5-12.0 Hz) frequency band for two composite scalp locations previously identified by principal components analyses (bilateral fronto-central and bilateral centro-parietal-occipital). Genotypes were determined for a panel of 791 micro-satellite polymorphisms in 410 members of multiplex families using SOLAR.ResultsSixty percent of this study population had a lifetime diagnosis of alcohol dependence. Analyses of multipoint variance component LOD scores, for the EEG alpha power phenotype, revealed two loci that had a LOD score of 3.0 or above for the fronto-central scalp region on chromosomes 1 and 6. Additionally, 4 locations were identified with LOD scores above 2.0 on chromosomes 4, 11, 14, 16 for the fronto-central location and one on chromosome 2 for the centro-parietal-occipital location.ConclusionThese results corroborate the importance of regions on chromosome 4 and 6 highlighted in prior segregation studies in this and other populations for alcohol dependence-related phenotypes, as well as other areas that overlap with other substance dependence phenotypes identified in previous linkage studies in other populations. These studies additionally support the construct that EEG alpha recorded from fronto-central scalp areas may represent an important endophenotype associated with alcohol and other substance dependence.

REVIEW: Human and laboratory rodent low response to alcohol: is better consilience possible?

If people are brought into the laboratory and given alcohol, there are pronounced differences among individuals in many responses to the drug. Some participants in alcohol challenge protocols show a cluster of 'low level of responses to alcohol' determined by observing post-drinking-related changes in subjective, motor and physiological effects at a given dose level. Those individuals characterized as having low level of response (LR) to alcohol have been shown to be at increased risk for a lifetime diagnosis of alcohol dependence (AD), and this relationship between low LR and AD appears to be in part genetic. LR to alcohol is an area where achieving greater consilience between the human and the rodent phenotypes would seem to be highly likely. However, despite extensive data from both human and rodent studies, few attempts have been made to evaluate the human and animal data systematically in order to understand which aspects of LR appear to be most directly comparable across species and thus the most promising for further study. We review four general aspects of LR that could be compared between humans and laboratory animals: (1) behavioral measures of subjective intoxication; (2) body sway; (3) endocrine responses; and (4) stimulant, autonomic and electrophysiological responses. None of these aspects of LR provide completely face-valid direct comparisons across species. Nevertheless, one of the most replicated findings in humans is the low subjective response, but, as it may reflect either aversively valenced and/or positively valenced responses to alcohol as usually assessed, it is unclear which rodent responses are analogous. Stimulated heart rate appears to be consistent in animal and human studies, although at-risk subjects appear to be more rather than less sensitive to alcohol using this measure. The hormone and electrophysiological data offer strong possibilities of understanding the neurobiological mechanisms, but the rodent data in particular are rather sparse and unsystematic. Therefore, we suggest that more effort is still needed to collect data using refined measures designed to be more directly comparable in humans and animals. Additionally, the genetically mediated mechanisms underlying this endophenotype need to be characterized further across species.

Acculturation Stress, Anxiety Disorders, and Alcohol Dependence in a Select Population of Young Adult Mexican Americans

Mexican Americans comprise one of the most rapidly growing populations in the U.S. and within this population the process of acculturation has been suggested to be associated with some mental health problems. This study sought to ascertain quantitative information indexing acculturation stress and its association with mental health disorders in a select community sample of Mexican Americans. Demographic information, DSM-III-R diagnoses, and information on cultural identity and acculturation stress were obtained from 240 Mexican American young adults that were recruited by fliers and were residing in selected areas of San Diego. No associations were found between measures of cultural identification and lifetime diagnoses of drug or alcohol dependence, major depressive disorder, anxiety disorders or antisocial personality disorder/conduct disorder in this sample of Mexican American young adults. However, lifetime diagnoses of alcohol dependence, substance dependence, and anxiety disorders were associated with elevations in acculturation stress. Quantitative measures of acculturation stress, but not cultural identity per se, were found to be significantly associated with substance dependence and anxiety disorders in this select population of Mexican American young adults. These data may be helpful in designing prevention and intervention programs for this high risk population.

Drinking trajectories from adolescence to the fifties among alcohol-dependent men.

Although it has been recognized that the course of alcoholism may differ across individuals, little work has characterized drinking trajectories from drinking onset to midlife. The current study examined trajectories of alcohol dependence from adolescence to the mid-50s in a sample of 420 men with a lifetime diagnosis of alcohol dependence. Men from the Vietnam Era Twin Registry were given the Lifetime Drinking History, which assesses the patterns of alcohol consumption and diagnostic symptoms for self-defined drinking phases. Phase data were converted into person-year data, with alcohol-dependence diagnosis coded as present or absent for each of 13 age groupings, starting with up to age 20 and ending with ages 54-56. Latent growth mixture modeling was used to define four drinking trajectories: young-adult, late-onset, severe-nonchronic, and severe-chronic alcoholics. Further analyses with other diagnostic variables, other drinking variables, alcohol expectancies, personality scales, and religiousness scores were completed to differentiate men best categorized by each trajectory. Extension of Latent Growth Mixture Modeling (LGMM) into the mid-50s revealed that, although some individuals remain chronic alcohol users, others decline in alcohol problem use. Differences seen among these groups may help in the treatment of alcohol dependence, such that more energy can be spent treating those likely to be in the more severe trajectories.

Drug Abuse by Adolescents: General Considerations

1. Ximena Sanchez-Samper, MD* 2. John R. Knight, MD* 1. *Center for Adolescent Substance Abuse Research, Children's Hospital Boston, Boston, Mass After completing this article, readers should be able to: 1. Discuss current trends in adolescent substance use and the specific substances used most commonly among 8th, 10th, and 12th graders. 2. Identify risk and protective factors, including genetic and environmental correlates, for the initiation of substance use in adolescents. 3. Discuss the most common concomitant mental health disorders and how they can affect the course of diagnosis and treatment for substance abuse. 4. Delineate the variety of treatment options available. 5. Describe the role of the pediatrician in educating patients and families on substance abuse prevention; performing screening and initial assessments; and providing support, brief counseling, or referrals for in-depth treatment. Adolescence is a time of physical, emotional, and psychological maturation as well as a period of searching for independence and experimentation. One area of experimentation associated with adolescence is substance use. (1) Although many adolescents experiment with drugs and alcohol from time to time without enduring problems, those who develop the disorders of substance abuse and dependence make substance use a major public health concern. The Monitoring the Future Study (MTFS) is a nationwide survey measuring smoking, drinking, and illicit drug use among nearly 50,000 8th, 10th, and 12th graders in more than 400 secondary schools in the United States each year. (2)(3) According to the 2006 overview of findings from the MTFS, approximately one fifth (21%) of today's 8th graders, more than one third (36%) of 10th graders, and nearly half (48%) of all 12th graders reported using an illicit drug at least once during their lifetimes. Despite a minimum legal age requirement to purchase alcohol, 6% of 8th graders, 19% of the 10th graders, and 30% of the 12th graders self-reported drunkenness during the month prior to being interviewed. (2)(3) Among the problems experienced by adolescents who use alcohol and drugs are …

Disinhibitory psychopathology and delay discounting in alcohol dependence: personality and cognitive correlates.

Increased discounting of delayed rewards may reflect a decision bias that contributes to excessive use of alcohol and more generally, to an impulsive, disinhibitory predisposition that is characterized by a preference for immediate over long-term rewards. The current study examined the association between delay discounting of rewards and the covariation among several types of disinhibitory problems that are often comorbid with alcohol dependence (AD). Lifetime problems with alcohol, marijuana, other drugs, childhood conduct disorder, and adult antisocial behavior were assessed in a sample of 426 young adults, 257 of whom had a lifetime diagnosis of AD. Higher delay discounting rates were associated with the covariation among all domains of disinhibitory problems and were not uniquely associated with any one domain. Higher delay discounting rates also were associated with lower intelligence, lower working memory capacity, and higher trait impulsivity. The results suggest that increased delay discounting of rewards may reflect aspects of a general vulnerability to externalizing, disinhibitory disorders.

CLINICAL STUDY: P3 components of the event‐related potential and marijuana dependence in Southwest California Indians

Native Americans have some of the highest rates of marijuana use and abuse, yet neurobiological measures associated with addiction to marijuana in this population remain unknown. The present investigation evaluated associations between the P350 and P450 components of the event-related potential (ERP) elicited by affective stimuli, and marijuana dependence in a population of Southwest California (SWC) Indian adults. Three hundred and seventeen participants with a mean age of 30 years who were free of major Axis I and psychiatric diagnoses and antisocial personality disorder were categorized as: (1) no marijuana use disorders or other drug dependence diagnoses; (2) marijuana dependence and no other drug dependence diagnoses; and (3) marijuana dependence and other drug dependence diagnoses. ERPs were collected using a facial discrimination task that generated a late positive component with two peaks at approximately P350 and P450 milliseconds. Multivariate analyses of variance was used to detect associations between the two component peaks and the three participant groups taking into consideration age, gender and the presence of a lifetime diagnosis of alcohol dependence. Increases in the latency of both the P350 and P450 component peaks were found to be associated with the diagnosis of marijuana dependence and marijuana dependence co-morbid with other drug dependence. Women appeared to be more impacted than men are. A diagnosis of marijuana dependence was not associated with any changes in late component amplitudes. Taken together these studies suggest that marijuana dependence may be associated with delays in the evaluation and identification of emotional stimuli in SWC Indians.

SASSI: A REPLY TO THE CRITIQUE OF FELDSTEIN &amp; MILLER (2007)

SASSI: A REPLY TO THE CRITIQUE OF FELDSTEIN &amp; MILLER (2007)

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders

EXAMINING TREATMENT USE AMONG ALCOHOL-DEPENDENT INDIVIDUALS FROM A POPULATION PERSPECTIVE

To assess the prevalence of treatment use in lifetime and past year alcohol dependent respondents. To establish the proportion of problem drinkers who use alcohol treatment that just go to one treatment versus attending multiple different types of treatment in the same year. To explore what treatments are most likely to form part of a multiple treatment package. Analysis of the 2001-2002 National Epidemiologic Survey of Alcohol and Related Conditions, a large (N = 43 039), representative survey of the non-institutionalized adult population of the USA. There were 4781 respondents who met criteria for a lifetime definition of alcohol dependence and 1484 respondents who met criteria for past year alcohol dependence. Prevalence of lifetime use of alcohol treatment was 25% among those with a lifetime diagnosis of alcohol dependence. Prevalence of past year use of alcohol treatment was 12% among respondents with past year alcohol dependence. Only one-third of past year treatment users had accessed just one type of alcohol treatment. While treatment services are only used by the minority of people with alcohol dependence, those people who do access alcohol treatment are likely to use several different alcohol treatment services in the same year.