[Demoralisation in alcohol-dependent patients with co-occurring psychiatric disorders]. / Demoralisatie bij patiënten met alcoholafhankelijkheid en comorbide psychiatrische stoornissen.

BACKGROUND: Demoralisation is a multidimensional concept, with helplessness and hopelessness as its key elements. Many patients, both in somatic and in mental health care, suffer from demoralisation. In the process of recovery, remoralisation constitutes a first step.
AIM: To investigate demoralisation in alcohol-dependent inpatients with co-occurring psychiatric disorders.
METHOD: Included in this study were 159 alcohol-dependent inpatients admitted to clinics for dual diagnosis. Demoralisation was assessed at treatment entry and again one month later.
RESULTS: A strong level of demoralisation was found, particularly in the co-occurrence of depression, anxiety and personality disorders. At treatment entry, 92% of patients was clinically demoralised and, one month later, this was 89%. In patients with co-occurring depression, mood and personality disorders, a significant decrease of demoralisation was found after one month, whereas in patients with developmental and psychotic disorders this was not the case. In 11% of patients there was clinically relevant improvement and in 7.5% there was clinically relevant deterioration; the latter mainly in patients with co-occurring developmental and psychotic disorders.
CONCLUSION: At start of treatment, these alcohol-dependent patients were strongly demoralised, especially in the co-occurrence of psychiatric disorders. Although there was a significant improvement in demoralisation after one month of treatment, patients remained strongly demoralised. In one in ten patients there was clinically relevant remoralisation. As a first step in the process of recovery, clinicians should pay more attention to remoralisation. Targeted interventions, aimed at this specific population, are necessary.

[Refeeding syndrome during alcohol detoxification]. / Refeedingsyndroom bij alcoholdetoxificatie.

Refeeding syndrome (RS) can occur when malnourished patients are reintroduced to carbohydrates. The symptoms are caused by a combination of electrolyte shifts and fluid retention. Symptoms are wide-ranging; some patients may suffer from harmless muscle cramps, others from more severe neurological and cardiological symptoms that can even lead to death. Although alcohol dependence is a risk factor for the development of RS, little attention is being given to this problem in addiction treatment. In this article we report a case of RS that occurred during alcohol detoxification. We also present the results of a pilot study on the incidence of RS during the alcohol detoxification of 12 patients.

[Detoxification of patients with GHB dependence]. / Detoxificatie van patiënten met GHB-afhankelijkheid.

BACKGROUND: A new detoxification method for GHB dependence was developed recently in the Netherlands. The method involves the use of pharmaceutical GHB. AIM: To describe the characteristics of GHB dependent inpatients, the course of the detoxification process and patients' progress in the three months following inpatient detoxification. METHOD: 229 GHB dependent patients were monitored during and after inpatient detoxification. Records were kept of the psychiatric symptoms, withdrawal symptoms and relapses. RESULTS: The average age of the patients was 29 years; 69% of the patients were male. They reported severe symptoms of co-occurring depression and anxiety. Detoxification was successful in 86% of the patients and, on a whole, the procedure ran smoothly, without complications. However, within three months following detoxification two-thirds of the patients had relapsed and were again taking GHB. CONCLUSION: Pharmaceutical GHB can be used as an alternative to the benzodiazepine method for detoxifying patients with GHB dependence. However, the high relapse rates following detoxification are of great concern.

[Clinical treatment of posttraumatic stress disorder in patients with serious dual diagnosis problems]. / Klinische behandeling van posttraumatische stressstoornis bij patiënten met ernstige dubbele diagnose.

Three patients with severe addiction problems, early sexual trauma, posttraumatic stress disorder PTSD comorbid psychotic vulnerability and personality problems received integrated treatment following admission to a clinic specialising in the care of patients with a dual diagnosis. Treatment was administered in accordance with current guidelines and involved either imaginal exposure or eye movement desensitization and reprocessing EMDR, integrated with relapse management of addiction problems. It is concluded that the current evidence-based guidelines regarding PTSD and addiction can also be applied successfully and effectively to an extremely vulnerable patient population.

Treatment goals in addiction healthcare: the perspectives of patients and clinicians.

BACKGROUND: Little is known about the perspectives of either patients or clinicians regarding treatment goals in addiction healthcare. In general, treatment goals involve abstinence or at least reduction of substance use. AIM: To examine and compare the treatment goals indicated by both patients and clinicians at baseline, interim and exit measurement. METHOD: A descriptive study was performed with multiple measurements of treatment goals. Patients (n = 111) and clinicians (n = 20) were recruited from three addiction treatment centres in the Netherlands. A Shared Decision Making Intervention (SDMI) was undertaken to promote and evaluate treatment agreement. RESULTS: Patients identified treatment goals of daytime activities and abstinence or reduced alcohol consumption as most important. Clinicians indicated psychological distress, daytime activities and substance use as most important. Differences between patients and clinicians were found for the treatment goals of physical health (patient > clinician) and psychological distress (clinician > patient). The results further showed that treatment goals of both patients and clinicians become more closely aligned during the course of treatment. CONCLUSION: SDMI provides a method to explore and discuss discrepancy between patients' and clinicians' goals of treatment which leads to convergence. Such convergence is likely to be a necessary prerequisite for positive treatment outcomes.

Shared decision-making reduces drug use and psychiatric severity in substance-dependent patients.

BACKGROUND: In the last decades, shared decision-making (SDM) models have been developed to increase patient involvement in treatment decisions. The purpose of this study was to evaluate a SDM intervention (SDMI) for patients dependent on psychoactive substances in addiction health care programs. The intervention consisted of a structured procedure to reach a treatment agreement and comprised 5 sessions. METHODS: Clinicians in 3 treatment centres in the Netherlands were randomly assigned to the SDMI or a standard procedure to reach a treatment agreement. RESULTS: A total of 220 substance-dependent patients receiving inpatient treatment were randomised either to the intervention (n = 111) or control (n = 109) conditions. Reductions in primary substance use (F((1, 124)) = 248.38, p < 0.01) and addiction severity (F((8)) = 27.76, p < 0.01) were found in the total population. Significant change was found in the total population regarding patients' quality of life measured at baseline, exit and follow-up (F((2, 146)) = 5.66, p < 0.01). On the European Addiction Severity Index, SDMI showed significantly better improvements than standard decision-making regarding drug use (F((1, 164)) = 7.40, p < 0.01) and psychiatric problems (F((1, 164)) = 5.91, p = 0.02) at 3-month follow-up. CONCLUSION: SDMI showed a significant add-on effect on top of a well-established 3-month inpatient intervention. SDMI offers an effective, structured, frequent and well-balanced intervention to carry out and evaluate a treatment agreement.

Systematic review of the effects of chronic disease management on quality-of-life in people with chronic obstructive pulmonary disease.

INTRODUCTION: Chronic disease management for patients with chronic obstructive pulmonary disease (COPD) may improve quality, outcomes and access to care. OBJECTIVE: To investigate effectiveness of chronic disease management programmes on the quality-of-life of people with COPD. METHODS: Medline and Embase (1995-2005) were searched for relevant articles, and reference lists and abstracts were searched for controlled trials of chronic disease management programmes for patients with COPD. Quality-of-life was assessed as an outcome parameter. Two reviewers independently reviewed each paper for methodological quality and extracted the data. RESULTS: We found 10 randomized-controlled trials comparing chronic disease management with routine care. Patient populations, health-care professionals, intensity, and content of the intervention were heterogeneous. Different instruments were used to assess quality of life. Five out of 10 studies showed statistically significant positive outcomes on one or more domains of the quality of life instruments. Three studies, partly located in primary care, showed positive results. CONCLUSIONS: All chronic disease management projects for people with COPD involving primary care improved quality of life. In most of the studies, aspects of chronic disease management were applied to a limited extent. Quality of randomized-controlled trials was not optimal. More research is needed on chronic disease management programmes in patients with COPD across primary and secondary care.

Identification of patients at high risk of noncompliance in substance dependence treatment.

Noncompliance in substance dependence treatment seriously threatens its effectiveness. Pretreatment identification of those at the highest risk allows targeting of specific compliance enhancing interventions to those who may benefit most from it. In a cohort of 292 patients entering a 30-day treatment program for substance abuse treatment, several potential predictors of noncompliance were recorded before treatment. Compliance was registered when treatment was discontinued before the 30th day. Logistic regression was used to identify independent predictors of noncompliance and the area under the receiver-operating characteristic (ROC) curve was quantified to assess their joint predictive value. Mean age was 35 years, 80% were male. During follow-up 31% became noncompliant. Independent predictors of noncompliance were male gender, less than 10 years of education, severity of medical and drug problems, and behavioral intention to comply with treatment. The area under the ROC curve was 0.70 (95% CI: 0.64-0.76). In conclusion, noncompliance in a substance abuse treatment program can be predicted using five easy to assess patient characteristics. These results may be useful in preventing noncompliant behavior early in treatment by motivational counseling strategies.

Association between interpersonal behaviour and helping alliance in substance-dependent patients.

This paper focuses on exploring the association between the patient's perception of his own interpersonal behaviour on the one hand, and that of the therapist's behaviour and of helping alliance on the other hand. A cross-sectional study was conducted, including 83 patients from substance dependence programs in The Netherlands. They completed the Helping Alliance Questionnaire (HAQ) and the Interpersonal Check List (ICL). Results indicate that the patient's perception of the therapeutic alliance, and his perception of his own and of the therapist's interpersonal behaviour are three separate domains, each playing their role in the context of the therapeutic relationship. Helping Alliance scores are predicted by both the patient's (complaisance) and the therapist's interpersonal behaviour (dominance). We conclude that patient's cognitions about himself and about his therapist do contribute significantly to the perception of the therapeutic relationship. Limitations to the study are discussed, as well as some clinical implications.

Retention in substance dependence treatment: the relevance of in-treatment factors.

In addition to "fixed" patient demographic and background variables, treatment process constructs play an important role in the prediction of treatment retention in substance dependence treatment. The objective of this paper is to analyze the predictive role of repeated measures of treatment readiness and behavioral intention, and of patients' perception of the therapeutic alliance, while controlling for fixed patient-oriented variables. Ninety-three patients, both alcohol and drug dependents, enrolled in this study, which was conducted in an inpatient treatment setting. Patients completed questionnaires shortly after admission (t=0) and approximately 2 weeks later (t=1). Using these measures, 35% of variance of a length of stay in treatment of up to 30 days could be explained. Fixed patient-oriented variables accounted for 21% of variance. Of the cognitive factors, helping alliance was the most important, accounting for an additional 8% of variance. The implications of these results are discussed.

Gender-role stereotypes and interpersonal behavior how addicted inpatients view their ideal male and female therapist.

This study focuses on the influences of self-perceived interpersonal behavior of addicted inpatients (n = 107) on the stereotypes of their ideal male and female therapist. Based on the interpersonal model of personality patients were asked to describe their ideal male and female therapist. Perceptions of interpersonal behavior of the ideal therapist are determined by the self-perceived interpersonal behavior of the patients rather than by their gender. Ideal therapists are described as managerial-autocratic and sociable-extravert, which is in almost perfect accordance with the self-perceptions of therapists. Although most of the patients prefer a female therapist, the interpersonal behavior of a male or a female therapist does not differ significantly. The results are discussed from the viewpoint that mutual expectations and preferences between patients and therapists are thought to be of crucial importance for the outcome of therapy. In the process of matching patients and therapists, these expectations should not only be assessed, but also used to improve the final matching.

The validity of the Self-Efficacy List for Drug Users (SELD).

In this study we evaluated the psychometric properties of the Self-Efficacy List for Drug users (SELD). Exploratory and confirmatory factor analyses on separate subject samples revealed that drug-users' self-efficacy was best described by three correlated dimensions: environmental factors, negative mood, and positive mood. The validity of this three-factor solution was supported by the pattern of associations with severity of drug use as assessed by the Addiction Severity Index. In addition, lower self-efficacy scores were related to a higher number of days of experiencing problems related to drug use. In conclusion we state that the SELD is a reliable and valid instrument to measure abstinence self-efficacy in drug users.

The Helping Alliance Questionnaire: psychometric properties in patients with substance dependence.

Psychometric properties of the Helping Alliance Questionnaire (HAQ) are analyzed in a population of 340 substance-dependent patients of an addiction clinic in the Netherlands. Factor analysis yields a two-factor structure: Cooperation and Helpfulness. The scales show fair correlations with three out of seven scales from the Barrett-Lennard Relationship Inventory. Length of Stay in Detox is predicted by scores on the Helpfulness scale and noncompliance by scores on the Cooperation scale. Besides this, intermediate outcome measures are correlated with HAQ scores. The HAQ seems to be a "quick scan" instrument to give a quick and global impression of the patients' perception of the quality of the working alliance with the therapist.