Initial preference for drinking goal in the treatment of alcohol problems: I. Baseline differences between abstinence and non-abstinence groups.

AIMS: To compare baseline characteristics of clients initially preferring abstinence with those preferring non-abstinence at the screening stage of a randomized controlled trial of treatment for alcohol problems (UKATT) and to identify predictors of goal preference from client characteristics present before the preference was stated. METHODS: From discussions with clients entering the trial (N = 742), screeners noted whether clients were aiming for abstinence 'probably yes' or 'probably no'. Differences between the two groups thus formed were explored by univariate comparisons among client characteristics recorded at baseline assessment and by logistic regression analysis with pre-existing characteristics as independent variables. RESULTS: Across all UKATT sites, 54.3% of clients expressed a preference for abstinence and 45.7% for non-abstinence. In univariate comparisons, clients preferring abstinence were significantly (P < 0.01) more likely to: (i) be female, (ii) be unemployed, (iii) report drinking more heavily but less frequently, (iv) have been detoxified in the 2 weeks prior to assessment, (v) report more alcohol problems, (vi) be in the action stage of change, (vii) report greater negative expectancies of drinking, (viii) report greater mental and physical ill-health, (ix) report less social support for drinking and (x) be more confident of their ability to resist heavy drinking in tempting situations. In the logistic regression model, the strongest predictors of goal preference were gender, drinking pattern, recent detoxification and social support for drinking. CONCLUSION: The implications of these findings for service delivery are best considered in conjunction with findings from a companion paper reporting treatment outcomes associated with each goal preference.

To what factors do clients attribute change? Content analysis of follow-up interviews with clients of the UK Alcohol Treatment Trial.

The UK Alcohol Treatment Trial compared outcomes after a social treatment (Social Behavior and Network Therapy) and a motivational treatment (Motivational Enhancement Therapy). As part of the process element of the trial, a subsample of clients were interviewed 3 months after treatment allocation and another subsample 12 months after allocation (N = 397) to explore the factors to which clients attributed positive changes that might have occurred in their drinking. Postinterview reports were content analyzed using three types of code: social, motivational, and general. At 3 months, Social Behavior and Network Therapy clients made significantly more social attributions and Motivational Enhancement Therapy clients more motivational attributions, and the difference for motivational attributions was maintained at 12 months (with a trend for social attributions). Overall, the factors to which change was most frequently attributed were involvement of others in supporting behavior change (a social factor), awareness of the consequences of drinking (a motivational factor), and three general factors--determination, commitment, and decision; detoxification or medication; and feeling comfortable talking. Change was more frequently attributed to general factors than it was to either social or motivational ones. Some of the difficulties in eliciting and coding attribution material are referred to. The results may help understand the absence of between-treatment type outcome differences in UK Alcohol Treatment Trial and other trials.

Folate augmentation of treatment - evaluation for depression (FolATED): protocol of a randomised controlled trial.

BACKGROUND: Clinical depression is common, debilitating and treatable; one in four people experience it during their lives. The majority of sufferers are treated in primary care and only half respond well to active treatment. Evidence suggests that folate may be a useful adjunct to antidepressant treatment: 1) patients with depression often have a functional folate deficiency; 2) the severity of such deficiency, indicated by elevated homocysteine, correlates with depression severity, 3) low folate is associated with poor antidepressant response, and 4) folate is required for the synthesis of neurotransmitters implicated in the pathogenesis and treatment of depression. METHODS/DESIGN: The primary objective of this trial is to estimate the effect of folate augmentation in new or continuing treatment of depressive disorder in primary and secondary care. Secondary objectives are to evaluate the cost-effectiveness of folate augmentation of antidepressant treatment, investigate how the response to antidepressant treatment depends on genetic polymorphisms relevant to folate metabolism and antidepressant response, and explore whether baseline folate status can predict response to antidepressant treatment. Seven hundred and thirty patients will be recruited from North East Wales, North West Wales and Swansea. Patients with moderate to severe depression will be referred to the trial by their GP or Psychiatrist. If patients consent they will be assessed for eligibility and baseline measures will be undertaken. Blood samples will be taken to exclude patients with folate and B12 deficiency. Some of the blood taken will be used to measure homocysteine levels and for genetic analysis (with additional consent). Eligible participants will be randomised to receive 5 mg of folic acid or placebo. Patients with B12 deficiency or folate deficiency will be given appropriate treatment and will be monitored in the 'comprehensive cohort study'. Assessments will be at screening, randomisation and 3 subsequent follow-ups. DISCUSSION: If folic acid is shown to improve the efficacy of antidepressants, then it will provide a safe, simple and cheap way of improving the treatment of depression in primary and secondary care. TRIAL REGISTRATION: Current controlled trials ISRCTN37558856.

The clients' perspective on change during treatment for an alcohol problem: qualitative analysis of follow-up interviews in the UK Alcohol Treatment Trial.

AIM: To develop a model of change during and following professional treatment for drinking problems, grounded in clients' accounts. PARTICIPANTS: Subsets of consecutively selected clients of the UK Alcohol Treatment Trial (UKATT), followed-up at 3 months (n = 211) and 12 months (n = 198) after randomization. Location Five statutory and non-statutory alcohol problems treatment agencies in three areas of England and Wales. Data Open-ended interviews conducted according to a brief interview guide, leading to 400-800-word post-interview reports used for analysis (tape-recordings used for auditing purposes). ANALYSIS: Reports analysed by a team according to grounded theory principles, involving an iterative process with successive refinement of interviewing and analysis with each successive batch of data. FINDINGS: A model of change from the clients' perspective was developed. Treatment was seen by clients as facilitating various changes in ways of thinking and/or increased support of various kinds from family and friends, along with new ways of acting in relation to drinking or more generally. For many those changes had led to an appreciation of the benefits accruing to them. Treatment was seen as part of a broader treatment system which included pretreatment assessment, forms of help additional to the trial treatment, plus an element of self-directed change during and following treatment. Taken with awareness of worsening alcohol-related harms, triggering events and external influence to seek treatment (the catalyst system), to which clients continued to refer following treatment, the change process is depicted as a complex, ongoing set of systems in which a trial treatment is embedded. CONCLUSIONS: Models of change should be broadened so that treatment is seen as a complex system of parts, facilitating a nexus of cognitive, social and behavioural changes, embedded within a broader system of events and processes catalysing change. Such a model helps explain the relative absence of between-treatments outcome differences in UKATT and in the alcohol problems treatment and more general psychotherapy research literatures.