Evaluation of screening and brief intervention for hazardous alcohol use integrated into clinical practice in an inner-city Emergency Department.

INTRODUCTION: In small studies, Screening, Brief Intervention and Referral to Treatment (SBIRT) in Emergency Departments (EDs) is effective in reducing hazardous alcohol use. OBJECTIVE: To examine the effectiveness of SBIRT at an inner-city ED in routine clinical practice. METHODS: Of the 41 900 consecutive ED patients aged 18 years and older, 22 537 (53.8%) were screened using the Alcohol Use Disorders Identification Test (AUDIT-C). Patients with positive AUDIT-C scores (men≥5 and women≥4) received educational leaflets. Brief interventions were performed by ED personnel trained in motivational interviewing. At 3 months, patients were contacted by telephone and recent drinking pattern was assessed. RESULTS: Out of 22 537 patients, 2209 (9.8%) had an elevated AUDIT-C score. Male sex, alcohol-related reason for ED visit, alcohol or other intoxication at ED visit, head injury, stomach or intestinal bleeding and wounds were significant predictors of hazardous alcohol use in both univariate and multivariate analysis (all P<0.001). Out of 2209 patients, 894 (40.5%) AUDIT-C-positive patients received an intervention: of these 894 patients, 70% received educational material and 30% received motivational intervention and educational material. In the subset of patients available for follow-up, 34.9% either reduced or stopped alcohol use. CONCLUSION: Our study shows that in a large inner-city ED, SBIRT can be implemented in daily care. Screening uncovered large numbers of patients with hazardous alcohol use and identified several risk factors. Moreover, screening and intervention appeared to be effective in reducing alcohol intake.

Obsessions in normality and psychopathology.

BACKGROUND: This study examines the presence of obsessions in the general population and in various psychiatric disorders. Second, the impact of obsessions is studied in terms of general functioning and quality of life in the general population. METHODS: Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a large representative sample of the Dutch population (n = 7,076). Diagnostic criteria were assessed by the Composite International Diagnostic Interview (CIDI). The association of quality of life and obsessions on each subject was assessed by using Short Form 36 Health Survey (SF-36) and General Health Questionnaire (GHQ). RESULTS: Obsessions occurred frequently in the general population: the lifetime prevalence of obsessions was 5.3% and the 12-month prevalence was 1.7%. Subjects with obsessions scored significantly worse (P<.0001) on all eight dimensions of the SF-36 as well as on the GHQ. When controlling for the presence of any mental disorder, the negative association of obsessions and low general health and well-being remained significantly intact. In patients with a psychiatric disorder, obsessions had a lifetime prevalence of 10.3% and a 12-month prevalence of 6.8%. CONCLUSIONS: Obsessions are common phenomena in the general population and are associated with decreased functioning in several areas of health and well-being. Furthermore, they occur frequently in the presence of various psychiatric disorders. Obsessions should be perceived, similar to delusions, as a distinct dimension across psychiatric disorders rather than a mere symptom of OCD.

The three year course of alcohol use disorders in the general population: DSM-IV, ICD-10 and the Craving Withdrawal Model.

AIMS: To determine the course of alcohol use disorders (AUD) in a prospective general population study using three different classification systems: Diagnostic and Statistical Manual version IV (DSM-IV), International Classification of Diseases version 10 (ICD-10) and the craving withdrawal model (CWM). The latter is an alternative classification, which requires craving and withdrawal for alcohol dependence and raises the alcohol abuse threshold to two criteria. DESIGN, SETTING AND PARTICIPANTS: Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a large (n=7,076) representative general population study with a baseline and 1- and 3-year follow-up assessments. MEASUREMENTS: Diagnostic status according to DSM-IV, ICD-10 and CWM at baseline and at follow-up was established using a structured interview (Composite International Diagnostic Interview: CIDI). FINDINGS: DSM-IV abuse, ICD-10 harmful use and CWM abuse all showed a favourable course with remission rates of 81, 89 and 71%, respectively, at 1-year follow-up and 85, 92 and 79% at 3-year follow-up. Dependence according to DSM-IV, ICD-10 and CWM had a somewhat less favourable course, with remission rates (no dependence) of 67, 67 and 57% at 1-year follow-up and 74, 69 and 73% at 3-year follow-up, respectively. Subjects who were remitted at 1-year follow-up showed relapse-rates of 0-14% for dependence and 4-12% for abuse at 3-year follow-up. Although CWM diagnoses tended towards greater diagnostic stability than DSM-IV and ICD-10, most differences were not significant. CONCLUSION: The conviction that addiction is a chronic relapsing disease may apply to treatment-seeking alcoholics, but our data show a far more favourable course of alcohol use disorders in the general population.

The Bayesian Alcoholism Test had better diagnostic properties for confirming diagnosis of hazardous and harmful alcohol use.

OBJECTIVE: Conventional tests for alcoholism fail to confirm hazardous and harmful alcohol use (HHAU) accurately and objectively. We validated a Bayesian Alcoholism Test (BAT) for confirming the diagnosis of HHAU. STUDY DESIGN AND SETTING: BAT is based on studies on the prevalence of HHAU and other diseases causing similar abnormalities, and on conditional probabilities of these disorders and associated biochemical markers and clinical signs. BAT was compared to carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) in treatment-seeking alcoholics, non-treatment-seeking heavy drinkers, and controls. Main outcome measures were test sensitivity and specificity, likelihood ratios, and receiver-operating characteristic (ROC) curves. RESULTS: Comparing alcoholics and controls, sensitivity of BAT (94%) was significantly higher than CDT (63%) and GGT (73%). The area under the ROC curve for BAT (.989) was significantly higher than the area under the curve for CDT (.909) and area under the curve for GGT (.902). Using pooled data of all 182 subjects included in the study, the amount of drinking had a significant better correlation coefficient with BAT (.795) than with CDT (.657), and GGT (.604). CONCLUSION: BAT has better diagnostic properties than CDT and GGT for confirming HHAU.

Alcohol abuse and dependence criteria as predictors of a chronic course of alcohol use disorders in the general population.

AIMS: To investigate whether DSM-IV abuse and dependence criteria and the ICD-10 criterion for craving differentially predict a chronic course of alcohol use disorders (AUD) in the general population. METHODS: Data were derived from the Netherlands Mental Health Survey and Incidence Study, a large representative sample of the general Dutch population with a baseline and a 1- and 3-year follow-up assessment. In the present study, a cohort of subjects with a DSM-IV AUD diagnosis at baseline was followed (n = 382). Diagnostic criteria of AUD according to DSM-IV and ICD-10 were assessed using the Composite International Diagnostic Interview (CIDI). RESULTS: In our cohort of subjects with an AUD diagnosis at baseline, the presence of all dependence criteria, except tolerance, significantly increased the risk for dependence at 1 and 3 years follow-up. Abuse criteria displayed much lower and often non-significant risks for dependence at follow-up, with the exception of the criterion 'legal problems'. The ICD-10 criterion 'craving' had the highest relative risk (RR) of all criteria for dependence at 1 year (RR = 12.4, 95% CI = 5.5-27.8) and 3 years follow-up (RR = 12.9, 95% CI = 4.4-37.7). CONCLUSION: With the exception of tolerance, all DSM-IV dependence criteria are useful in predicting the course of AUD in the general population.

The craving withdrawal model for alcoholism: towards the DSM-V. Improving the discriminant validity of alcohol use disorder diagnosis.

AIMS: To compare the discriminant validity of the DSM-IV and the ICD-10 classification of alcohol use disorders (AUD) with an alternative classification, the craving withdrawal model (CWM). CWM requires craving and withdrawal for the diagnosis of alcohol dependence and raises the alcohol abuse threshold to two DSM-IV AUD criteria. METHODS: Data were derived from The Netherlands Mental Health Survey and Incidence Study, a large representative sample of the general Dutch population. In the present study, only non-abstinent subjects were included (n=6041). Three diagnostic systems (DSM-IV, ICD-10, and CWM) were compared using the following discriminant variables: alcohol intake, psychiatric comorbidity, functional status, familial alcohol problems, and treatment sought. RESULTS: The year prevalence of CWM alcohol dependence was lower than the prevalence of ICD-10 and DSM-IV dependence (0.3% vs 1.4% and 1.4%). The year prevalence of abuse was similar for CWM and DSM-IV (4.7 and 4.9%), but lower for ICD-10 harmful use (1.7%). DSM-IV resulted in a poor distinction between normality and abuse and ICD-10 resulted in a poor distinction between harmful use and dependence. In contrast, the CWM distinctions between normality and abuse, and between abuse, and dependence were significant for most of the discriminant variables. CONCLUSION: This study indicates that CWM improves the discriminant validity of AUD diagnoses. The predictive validity of the CWM for alcohol and other substance use disorders remain to be studied.

Craving and withdrawal as core symptoms of alcohol dependence.

There is ongoing debate regarding the validity of the distinction of alcohol abuse and dependence, the distinction between normality and alcohol abuse, and the absence of craving in the DSM-IV classification of alcohol use disorders. In this study, we examine the discriminant validity of the DSM-IV alcohol use disorder diagnoses in three different populations (98 patients from an alcohol treatment service, 68 nontreatment-seeking heavy drinkers, and 75 psychiatric outpatients). We compare the results of the DSM-IV classification with an alternative classification that requires craving and withdrawal for the diagnosis of dependence and at least two DSM-IV abuse-dependence symptoms for the diagnosis of abuse: the Craving Withdrawal Model (CWM). Although the total prevalence of any alcohol use disorder did not differ between DSM-IV and CWM, the distinction between normality and abuse and between abuse and dependence was better for the CWM categories.