Recognition and management of depression in a substance use disorder treatment population.

This study examines the association between depressive symptomatology and return to substance use among a sample of 126 veterans consecutively admitted to treatment at a VA intensive outpatient program for substance use disorders. Controlling for numerous demographic and health-related covariates, depressive symptomatology measured at treatment exit with a Beck Depression Inventory (BDI) was significantly predictive of substance use at three-months post-treatment (p < .05). Analysis with a recoded BDI showed that the moderately-to-severely symptomatic (BDI = 20+) were 4.1 times more likely to have returned to substance use than those with a BDI score of under 20.

Short-term course of drinking in an untreated sample of at-risk drinkers.

OBJECTIVE: We know little about the short-term course of drinking, particularly the stability or instability of at-risk drinking in untreated drinkers. Because few at-risk drinkers obtain help for their drinking, it is important to understand the short-term fluctuations between at-risk drinking and full-fledged alcohol use disorders, as well as remission of at-risk drinking. METHOD: We used four waves of data (each 6 months apart) from a probability community sample of 733 at-risk drinkers in six states in the southern United States to determine variation in abstinence, drinking patterns and alcohol use disorders over a 2-year period. For this analysis, we excluded those who reported receiving services for drinking during the 2-year study period (retrospectively at baseline), leaving a sample size of 664 (444 male); 479 (306 male) completed all four interviews. RESULTS: Although the majority (88%) of the sample was nonabstinent throughout the study, we found significant decreases in average number of drinks per drinking day and recent (past 6 months) alcohol disorders, and an increase in 6-month abstinence. Almost 30% of those with no recent alcohol disorder at baseline (n = 280) later met diagnostic criteria in at least one interview. Of those with a recent alcohol disorder at baseline (n = 199), one third met criteria in at least two subsequent interviews. CONCLUSIONS: There is some evidence for short-term progression from at-risk drinking to alcohol disorder. However, there is stronger evidence for declining problems and a fluctuation in and out of recovery and relapse, which may reflect an effort to maintain controlled drinking. Understanding this short-term course is important for primary and secondary prevention efforts and for screening of at-risk drinking in primary care and in the workplace.

Depression after alcohol treatment as a risk factor for relapse among male veterans.

We examined the association between relapse-to-drinking and depressive symptomatology measured during inpatient treatment for alcohol disorder and 3 months posttreatment. Data were obtained from 298 veterans who completed 21-day inpatient treatment. Follow-up interviews were conducted at 3, 6, 9, and 12 months posttreatment. We used multiple logistic regression to assess the association between relapse and baseline/3-month posttreatment measures of depression (Beck Depression Inventory; BDI), controlling for important covariates. Our results showed that (a) the mild-to-moderately symptomatic participants (BDI = 14-19) at 3 months posttreatment were on average 2.9 times more likely than the nondepressed to have relapsed across follow-ups, and (b) the severely symptomatic participants (BDI = 20+) at 3 months posttreatment were on average 4.9 times more likely to have relapsed across follow-ups. Other analyses revealed that those with persistent depressive symptomatology reported at both baseline and 3 months posttreatment did not experience worse outcomes that those who reported symptomatology at 3 months posttreatment alone.

Quality Enhancement Research Initiative in Mental Health.

The Veterans Administration (VA) recently introduced its Quality Enhancement Research Initiative (QUERI) to facilitate the translation of best practices into usual clinical care. The Mental Health QUERI (MHQ) was charged with developing strategic plans for major depressive disorder (MDD) and schizophrenia. Twenty percent or more of VA service users are affected by 1 of these 2 disorders, disorders that often have a devastating impact on affected individuals. Despite the increasing availability of efficacious treatments for each disorder, substantial gaps remain between best practices and routine care. In this context, the MHQ identified steps critical to the success of a sustained process of rapid-cycle health care improvement for MDD and schizophrenia, including research initiatives to close gaps in knowledge of best treatment practices, demonstration projects to close gaps in practice and to expand understanding of effective strategies for implementing clinical guidelines, targeted enhancements of the VA information system, and research and dissemination initiatives to increase the availability of resources to support the accelerated incorporation of best practices into routine care. This article presents an overview of the elements in the initial MHQ strategic plans and the rationale behind them.

Gender differences in the relationships among SES, family history of alcohol disorders and alcohol dependence.

OBJECTIVE: Potential moderator and mediator roles of several measures of socioeconomic status (SES) were investigated for the relationship between a family history of alcoholism (FH) and alcohol dependence symptoms in adulthood. METHOD: These analyses were performed with a sample of 931 men and 385 women participating in studies at the Alcohol Research Center, University of Michigan. Hierarchical multiple regression equations were used to assess whether SES mediated and moderated relationships between FH and alcohol dependence symptoms. RESULTS: In general, measures of SES (education, occupation, personal and household income) were more important predictors of alcohol dependence symptoms among men, while FH was a stronger predictor among women. In the female sample, measures of personal and household income interacted with family history such that the influence of family history on adult alcohol dependence symptoms was significantly stronger among low income women. Measures of SES and FH were additively related to alcohol dependence symptoms among men. Education partially meditated the relationship between family history and alcohol dependence symptoms among men, indicating that the influence of family history on subsequent alcohol problems among men may be partially due to familial alcoholism's negative effect on educational attainment. CONCLUSIONS: The results of this study suggest the influence of FH on alcohol dependence varies according to SES and gender, and point to the usefulness of examining potential moderators and mediators of family history of alcohol use disorders.

Do patients with alcohol dependence use more services? A comparative analysis with other chronic disorders.

OBJECTIVE: The primary purpose of this research was to compare the service use of patients diagnosed with alcohol dependence to the service use of patients diagnosed with other chronic illnesses. The secondary purpose was to determine the impact of comorbid alcoholism on the service use of patients with chronic illnesses. METHODS: The sample included 67,878 veterans diagnosed with alcohol dependence, depression, or diabetes who were treated by the Department of Veterans Affairs in 1993. The number of inpatient days and outpatient visits over a 4-year period (1991 to 1995) were compared using regression models to control for differences in casemix. RESULTS: Controlling for casemix, patients treated for alcohol dependence had significantly fewer outpatient visits than patients treated for either depression or diabetes. Patients treated for alcohol dependence also had significantly fewer inpatient days than patients treated for depression, but significantly more inpatient days than patients treated for diabetes. Comorbid alcoholism was prevalent among patients treated for depression and diabetes. Comorbid alcoholism increased the number of inpatient days for patients treated for depression or diabetes and increased the number outpatient visits for patients with depression. However, comorbid alcoholism decreased the number of outpatient visits for patients treated for diabetes. CONCLUSIONS: Results suggest that patients with alcohol use disorders should not be singled out as being more costly to treat than patients with other chronic illnesses. These findings are in stark contrast to those from studies comparing individuals with alcohol use disorders to relatively healthy individuals sampled from at-risk populations.

Longitudinal changes in predictor profiles of abstinence from alcohol use among male veterans.

We examined variations in predictors of abstinence depending on the timing of follow-up after alcohol treatment using data from 298 males who completed inpatient treatment at a Midwestern VA Alcoholism Treatment Unit. Our findings indicate fluidity of abstinence and relapse across subjects in the 12 months posttreatment. We also found substantial shifts in the salience of predictors even across short periods of continued abstinence. Methodologically, these findings demonstrate the importance of multiple and closely spaced follow-up points in outcomes research. Substantively, our data support previous findings concerning the impact of increased medical severity, positive employment history, and depression on treatment outcomes.

Predicting problem drinking: a test of an interactive social learning model.

This study tested a social learning model and explored the direct and interactive relationships between personality and environment in predicting problem alcohol use. We used longitudinal data from a nonclinical sample of males and females first tested in adolescence and followed into young adulthood. Hierarchial regression analyses were used to test main effects and interaction models. The cross-sectional data supported an interactive social learning model. Both personality and environment variables significantly predicted problem drinking. Two interactions between heavy drinking peer groups and personality variables were significant. Contrary to our hypothesis, the direction of the interaction was negative. In contrast, the longitudinal analyses did not provide strong support for our interactive model. Personality variables were significant predictors longitudinally, but in only one analysis did an environment variable significantly predict problem drinking. Furthermore, none of the interactions was significant predictors over time. Overall, the findings suggest that social learning models based on the interaction of personality and environmental influences may be more appropriate for predicting concurrent, as opposed to future problems, and that future research should include person-environment interactions. In addition, cultural tolerance of heavy drinking may be an important determinant of the role of psychological vulnerability in the development of problem drinking.