Improving alcoholism treatment across the spectrum of services.

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The chair was Michael E. Hilton. The presentations were (1) The effects of brief advice and motivational enhancement on alcohol use and related variables in primary care, by Stephen A. Maisto, Joseph Conigliaro, Melissa McNiel, Kevin Kraemer, Mary E. Kelley, and Rosemarie Conigliaro; (2) Enhanced linkage of alcohol dependent persons to primary medical care: A randomized controlled trial of a multidisciplinary health evaluation in a detoxification unit, by Jeffrey H. Samet, Mary Jo Larson, Jacqueline Savetsky, Michael Winter, Lisa M. Sullivan, and Richard Saitz; (3) Cost-effectiveness of day hospital versus traditional alcohol and drug outpatient treatment in a health maintenance organization: Randomized and self-selected samples, by Constance Weisner, Jennifer Mertens, Sujaya Parthasarathy, Charles Moore, Enid Hunkeler, Teh-Wei Hu, and Joe Selby; and (4) Case monitoring for alcoholics: One year clinical and health cost effects, by Robert L. Stout, William Zywiak, Amy Rubin, William Zwick, Mary Jo Larson, and Don Shepard.

Optimizing the cost-effectiveness of alcohol treatment: a rationale for extended case monitoring.

There has been much research on and debate about the appropriate length of acute treatment for alcohol problems. In the United States, the lengthy and costly treatment programs of only a few years ago have been supplanted by ever-shorter and less intensive protocols, with little evidence that this trend will end soon. In this paper, we argue that, because of the chronic, recurrent nature of alcohol problems, an optimal system for delivering treatment services to alcoholics needs to focus on long-term engagement with clients. There is evidence from studies on research reactivity and telephone follow-up protocols that a low-intensity long-term protocol for maintaining contact with clients over time spans measured in years may result in better long-term clinical outcomes and reduced long-term health care utilization and costs. We describe a flexible long-term low-intensity follow-up protocol for alcohol abusers we call "case monitoring." This protocol is specifically designed to minimize long-term health-care use. We predict that such an intervention should be especially efficacious for women, persons with comorbid Axis I disorders, and persons lower in sociopathy. The design of a study to determine the clinical and health service effects of this intervention is also described.

Factors associated with help seeking and perceived dependence among cocaine users.

Motivational and decisional models suggest that those who seek help for substance use problems may differ from those who do not seek help in terms of their belief that substance use is creating social and personal negative consequences and their perceived dependence. In this study, help seeking for cocaine use was hypothesized to be a function of the negative consequences from cocaine, perceiving oneself as dependent on cocaine, quantity and frequency of use, cost of use, and route of administration. A sample of 161 substance abusers in treatment who had used any cocaine in the last 6 months completed questionnaires regarding the quantity, frequency, history, and perceptions of the consequences of their cocaine use. Of the 161 subjects, 113 (70.2%) had at some time sought help from someone for their cocaine use. After controlling for marital and employment status, a logistic regression revealed that the number of negative consequences experienced, feeling dependent on cocaine, and the amount of cocaine used were associated with seeking help for cocaine use. Additionally, a logistic regression was performed to determine factors associated with cocaine users' reporting that they feel dependent on cocaine. Significant variables included number of negative consequences experienced and frequency of use. Consistent with motivational and decisional models, results suggest that clients' motivation to seek help for cocaine use is related primarily to adverse consequences of use. Theoretical and clinical implications of results are discussed.

Development of a behavior analytically derived alcohol-specific role-play assessment instrument.

Social learning theory postulates that chronic alcohol abusers may have deficits in ability to cope with stressful situations, and these deficits may be associated with relapse after treatment. Attempts to study the hypothesized deficits have been hampered by methodological problems. Therefore, a behavior analytic procedure was used to develop 10 categories of situations based on over 600 drinking situations elicited from alcoholics. Role plays were developed for each of these categories, and samples of alcoholics in treatment were asked to respond as if they were trying not to drink. Videotaped responses were behaviorally rated by trained judges for skill and anxiety, and subjects completed self-report ratings of urge to drink, anxiety, difficulty and skill after each role play. Good interrater reliabilities and internal consistency were found across three samples of alcoholics, with virtually no gender differences. Previous and current investigations show the validity and utility of this instrument. The Alcohol Specific Role Play Test therefore shows promise as a means of assessing alcoholics' reactions to high-risk situations.

A Cocaine High-Risk Situations Questionnaire: development and psychometric properties.

Although high-risk situations have been identified for alcoholism, opiate abuse, and smoking, further research is needed to identify high-risk situations for cocaine abuse. A 233-item Cocaine High-Risk Situations Survey was developed based on a comprehensive literature review and was administered to 179 cocaine users in treatment. Situations that occurred infrequently or that were not often associated with cocaine use were eliminated and the remaining 89 items were factor analyzed using half the sample with confirmatory factor analysis on the remainder of the sample. Only one factor was found for frequency of cocaine use in these situations. The 21 items with high factor loadings and a diverse range of content were retained for subsequent analyses and renamed the Cocaine High-Risk Situations Questionnaire (CHRSQ). Reliability and convergent and discriminant validity of this scale were demonstrated. Frequency of alcohol use in the same situations was not significantly related to cocaine use and abuse, supporting discriminant validity. The findings suggest that the frequency of ongoing cocaine use is not determined by specific situations. Theoretical and clinical implications are discussed.

Alcohol abusers' and social drinkers' responses to alcohol-relevant and general situations.

Responses of alcohol abusers and social drinkers were compared on general and alcohol-specific problem situations using role-play methodology. Multiple responses were assessed including behavioral observational ratings, self-reports and psychophysiologic measures. There were few differences between groups in responses to the general situations. Alcohol abusers had higher urges to drink than did the social drinkers in both the general and the alcohol-specific situations. However, in response to the alcohol-specific situations, the alcohol abusers, compared to the social drinkers, were rated by judges as significantly less skillful, and they displayed more self-reported anxiety, had a higher frequency of occurrence of problem situations in the natural environment and reported greater perceived realism of the alcohol-specific situations. Psychophysiologic measures did not differentiate between the groups. Results are discussed with respect to the importance of situation specificity in understanding the precipitants of drinking and their treatment implications.

Communication skills training, communication skills training with family and cognitive behavioral mood management training for alcoholics.

To evaluate three promising social learning approaches to the treatment of alcoholism, 69 male alcoholics in standard inpatient treatment participated in either a communication skills training group (CST), a communication skills training group with family participation (CSTF) or a cognitive behavioral mood management training group (CBMMT). Alcoholics who received CST or CSTF drank significantly less alcohol per drinking day during 6-month follow-up than those in CBMMT. The groups did not differ in abstinence rates or latency to relapse. All groups improved in skill and anxiety on the extensive battery of process measures, including role-play tests of general and alcohol-specific coping skills, but those in CST improved most in skill in alcohol-specific high-risk role plays and in ability to relax after the role plays. Alcoholics' skill, response latency, anxiety and urge to drink during alcohol-specific role plays were highly correlated with treatment outcome, demonstrating the importance of including comprehensive process measures in treatment outcome research. Implications for patient-treatment matching and future research are discussed.

Irrational beliefs, urges to drink and drinking among alcoholics.

The relationship of various irrational beliefs to alcohol dependence, urges to drink, anxiety and drinking after treatment was investigated for 63 male alcoholics, using Jones' Irrational Beliefs Test (IBT). Alcohol dependence was most strongly associated with problem avoidance. Urges to drink, anxiety and difficulty during alcohol-related role-plays were strongly correlated with problem avoidance and dwelling on negative events. The IBT was unrelated to pretreatment drinking measures but did predict 6-month posttreatment drinking (n = 48) which suggests these beliefs can mediate treatment response. Feeling doomed by the past was the best predictor of both frequency of drinking and average quantity consumed during follow-up. Treatment implications include targeting specific beliefs for intervention.

The clinical effectiveness of pneumococcal vaccine in the elderly.

The effectiveness of pneumococcal vaccine in the immunocompetent elderly remains controversial. We report the results of a multicenter, case-control study of 244 controls and 122 patients, aged 55 years and older, hospitalized during a 5-year period with pneumococcal bacteremia, meningitis, or other bacteriologically confirmed pneumococcal infection. Two controls per patient were matched on the basis of admission date, hospital records, and underlying diseases. All subjects were selected without knowledge of immunization status with pneumococcal vaccine, and were excluded if there was evidence for immunosuppression due to disease or iatrogenic causes. The clinical effectiveness of the vaccine was calculated to be 70% (95% confidence intervals [CI], 37% to 86%) in this population, based on a Mantel-Haenszel point estimate of the odds ratio of 0.30 (95% CI, 0.14% to 0.63%; P less than 0.005). The clinical effectiveness of pneumococcal vaccine in preventing pneumococcal infection in the immunocompetent elderly approximates the vaccine's effectiveness in the general immunocompetent population.

Social skills and irrational beliefs: a preliminary report.

Recent studies have suggested that irrational beliefs, as measured by the Irrational Beliefs Test (IBT), may contribute to social skills deficits. However, studies evaluating the correspondence between irrational beliefs and behavioral indices of social skills and social anxiety have yet to be reported. IBT data obtained from social skill deficit patient populations also have yet to appear in the literature. The present study addresses these issues by presenting IBT data obtained from a sample of 63 psychiatric patients referred for assessment of social skills deficits and evaluating the relationship of these data and patients' performance on a standardized behavioral measure of social skills and social anxiety, the Simulated Social Interaction Test (SSIT); and, presenting a comparison between IBT subscale scores obtained from the psychiatric sample and those obtained from a large (n = 897) student sample. A weak relationship was found between two IBT subscales and the SSIT. A mean level difference between patients' performance and student norms was also found on four subscales of the IBT. Implications for further assessment and treatment research with the IBT, social anxiety and social skills are discussed.

Cognitive functioning of alcoholic females: an exploratory study.

The effects of long-term alcoholism on the cognitive functioning of female alcoholics was examined through direct comparisons to equivalent male alcoholics and to both male and female controls on a battery of neuropsychological tests. As expected male alcoholics demonstrated deficits in abstraction, memory and visuoperceptual functioning whereas female alcoholics demonstrated deficits in abstraction and visuoperceptual functioning only. Apparently alcoholic females have fewer cognitive deficits than equivalent alcoholic males. Specifically after 30 days of sobriety alcoholic females were no different than control males or females on tests of memory whereas male alcoholic males were impaired. This finding if replicated implies the possibility of less structural brain damage in female alcoholics than equivalent alcoholics.

Evaluation of a social-setting detoxication program.

Nonmedical social-setting detoxication (SSD) is proposed as a safe, cost-effective program which emphasizes referral to long-term treatment. An examination of patient characteristics, program safety, utilization and cost, referral rate, and patient-staff interaction at one SSD program indicated the viability of the SSD model.

Factors Influencing Four Rules For Determining The Number Of Components To Retain.

The performance of four rules for determining the number of components to retain (Kaiser's eigenvalue greater than unity, Cattell's SCREE, Bartlett's test, and Velicer's MAP) was investigated across four systematically varied factors (sample size, number of variables, number of components, and component saturation). Ten sample correlation matrices were generated from each of 48 known population correlation matrices representing the combinations of conditions. The performance of the SCREE and MAP rules was generally the best across all situations. Bartlett's test was generally adequate except when the number of variables was close to the sample size. Kaiser's rule tended to severely overestimate the number of components.

Effects of demand for performance, self-monitoring of arousal, and increased sympathetic nervous system activity on male erectile response.

Clinical programs for the treatment of impotence generally have been successful but without experimental verification of their individual components or factors associated with the development of impotence. Twenty-four normal males participated in an investigation comparing factors believed to inhibit or facilitate penile tumescence. The effects of demand for performance, self-monitoring of erection, and increased SNS activity, were evaluated. Subjects were exposed to sexual stimuli under these conditions and measurements of penile responses were taken. Results indicated that there were no differential effects on penile responses between demand and no-demand or between self-monitoring and no self-monitoring. Increased SNS activity appeared to facilitate loss of erection, but only after, and not during, the sexual stimulus. The clinical and theoretical implications of these findings are discussed, and suggestions are made for future research.