Leydig cell aging and hypogonadism.

Leydig cell testosterone (T) production is reduced with age, resulting in reduced serum T levels (hypogonadism). A number of cellular changes have been identified in the steroidogenic pathway of aged Leydig cells that are associated with reduced T formation, including reductions in luteinizing hormone (LH)-stimulated cAMP production, the cholesterol transport proteins steroidogenic acute regulatory (STAR) protein and translocator protein (TSPO), and downstream steroidogenic enzymes of the mitochondria and smooth endoplasmic reticulum. Many of the changes in steroid formation that characterize aged Leydig cells can be elicited by the experimental alteration of the redox environment of young cells, suggesting that changes in the intracellular redox balance may cause reduced T production. Hypogonadism is estimated to affect about 5 million American men, including both aged and young. This condition has been linked to mood changes, worsening cognition, fatigue, depression, decreased lean body mass, reduced bone mineral density, increased visceral fat, metabolic syndrome, decreased libido, and sexual dysfunction. Exogenous T administration is now used widely to elevate serum T levels in hypogonadal men and thus to treat symptoms of hypogonadism. However, recent evidence suggests that men who take exogenous T may face increased risk of stroke, heart attack, and prostate tumorigenesis. Moreover, it is well established that administered T can have suppressive effects on LH, resulting in lower Leydig cell T production, reduced intratesticular T concentration, and reduced spermatogenesis. This makes exogenous T administration inappropriate for men who wish to father children. There are promising new approaches to increase serum T by directly stimulating Leydig cell T production rather than by exogenous T therapy, thus potentially avoiding some of its negative consequences.

Meta-Analysis of social relationships and posttreatment drinking outcomes: comparison of relationship structure, function and quality.

OBJECTIVE: Alcoholism treatment programs are recognizing the importance of social relationships by addressing interpersonal as well as intrapersonal factors in treatment. This shift in treatment orientation is occurring, however, in the absence of extensive information on the magnitude of the relationship between interpersonal factors and drinking outcomes. This article examines the association between alcoholism treatment drinking outcomes and social relationships. METHOD: Studies of the relationship between drinking outcomes and social relationships reported from 1965 to 1996 were coded for inclusion in this study. Analysis was a conceptually based meta-analytic review and synthesis of some of these findings. Through illustration, the manner in which components of social relationships (structure, function and quality) are associated with drinking outcomes was analyzed. RESULTS: Marital status, a structural construct, was less strongly correlated with drinking outcomes (average r = 0. 11) than was social support, a functional construct (average r = 0.22) or marital and family adjustment, a construct indicative of quality (average r = 0.17). Marital status was more strongly related to drinking outcomes for men than for women, whereas having significant others in treatment predicted stronger relationships between drinking outcomes and both social support and marital/family adjustment for both genders. CONCLUSIONS: The effect of social relationships on drinking outcomes is variable, inconsistent and weak. That this is not the case for some subpopulations and constructs encourages us to continue the examination of these complex interrelationships.

Alcohol treatment research follow-up interviews and drinking behaviors.

OBJECTIVE: This study, drawing upon data collected as part of a randomized clinical trial of alcohol treatment matching effects, investigates the relationship between research follow-up assessment interviews and subsequent drinking behaviors. METHOD: Subjects (N = 188; 143 men) participated in a day hospital substance-use disorder treatment program at either a private psychiatric hospital (n = 151) or a community hospital (n = 37) and were classified into one of three research groups: regularly scheduled follow-up interviews, missed scheduled follow-up interviews, and delayed Year-2 follow-up interviews. Complete data relevant to the present study were collected on 157 subjects. RESULTS: Study results provided support for a subject reactivity effect related to the research follow-up interview; that is, those subjects classified within the regularly scheduled follow-up interviews condition had the better drinking outcomes. Furthermore, by the end of the second follow-up year, subjects classified within the delayed Year-2 follow-up interviews condition had the poorest drinking outcomes. CONCLUSIONS: There may be considerable potential for subject reactivity effects, specific to the research assessment interview, to confound study results. Therefore, the interpretation of data from alcohol treatment outcome studies that fail to control for such potential confounding effects must be viewed with caution. Researchers are advised to control for these potentially confounding effects via methodological and/or statistical mechanisms.

General and alcohol-specific social support following treatment.

Both general and alcohol-specific support have been shown, albeit inconsistently, to affect drinking behavior. The discrepant findings may be clarified by examining how they work together. In exploratory analysis of clients following private outpatient alcoholism treatment, we found that the two variables add uniquely to the explanation of the variance in proportion of days abstinent (PDA). Both contribute significantly in the short term (3 months posttreatment), but only alcohol-specific support helps to explain variance over the longer term (15 months posttreatment), and alcohol-specific support explains more of the variance in PDA than general support at both time periods. More complex relationships are operating when short-term treatment effects have diminished. Alcohol-specific support mediates the relationship between general support and PDA, and both general social support and alcohol-specific support are moderators of one another in their relationships to PDA. Knowing how different types of social support affect drinking behavior at different intervals following treatment may help treatment providers to better prepare their clients for the posttreatment social environment.

Interpersonal factors and post-treatment drinking and subjective wellbeing.

AIMS: A conceptual clarification of the domain of social relationships defines three aspects of social relationships (structure, function and quality), which have both alcohol-specific and general components. We analyse the correlations among post-treatment indicators of social relationships and the association between these interpersonal variables and post-treatment drinking and subjective wellbeing. DESIGN: This is a secondary analysis of data from an alcohol treatment outcome study, in which subjects were randomly assigned to one of three treatment conditions and followed for 18 months. SETTING: The outpatient treatment program is located within a private psychiatric hospital in the north-eastern United States. PARTICIPANTS: We analyzed the 140 subjects who completed a social network instrument 12 months following treatment assignment. INTERVENTION: This secondary analysis combined clients from three treatment conditions, all of which were based upon social learning theory. MEASUREMENTS: Interview and questionnaire self-report data were collected by trained interviewers. FINDINGS: Indicators of social relationships are found to be relatively independent of one another. Only alcohol-specific social relationship indicators are significantly associated with drinking outcomes, and only general indicators are significantly associated with subjective wellbeing. Functional indicators, addressing social interaction content, have stronger effects on outcomes than structural or quality indicators. General and alcohol-specific support from friends have more influence than support from family; both surpass the influence of co-workers. CONCLUSIONS: A better understanding of the roles of social relationships during the course of treatment and recovery or relapse may help clarify how treatment personnel can utilize clients' interpersonal relationships more effectively to maximize treatment effectiveness.

The quality of cost data. A caution from the Department of Veterans Affairs experience.

Many health care system, including that of the Department of Veterans Affairs (VA), are facing dramatic changes as they adapt to state-level reform legislation and move into managed care environments. As new costing systems are designed and as researchers seek to conduct cost-effectiveness studies to guide health policy, it is critical to examine the assumed validity of the measurement procedures on which these costing systems are based. The foundation for VA health care costing is the cost distribution report, which is created by combining data on expenditures and workload with local service chiefs' estimates of program staffing and resource use. To evaluate the accuracy of the cost distribution report, the authors compared data from the report to cost data obtained in three multisite studies. Substantial differences were found between the cost distribution report and these independent sources, suggesting that researchers should not place uncritical reliance on the cost distribution report. The accuracy of costing data in information systems being implemented by VA will be limited to the extent they rely on the existing VA cost distribution system. Several strategies can be used in studies with a cost component to compensate for imperfect cost distribution systems.

Matching treatment focus to patient social investment and support: 18-month follow-up results.

Patients were randomly assigned to 1 of 3 treatments: brief broad-spectrum (BBS), extended relationship enhancement (ERE), or extended cognitive-behavioral (ECB). A hierarchical latent growth model was used to analyze the data of 188 patients (82%) followed for 18 months. ERE treatment was significantly more effective in increasing abstinence of patients entering treatment with a network unsupportive of abstinence or with a low level of investment in their network, whereas BBS treatment was more effective for patients with either (a) both a social network unsupportive of abstinence and a low level of network investment or (b) high investment in a network supportive of abstinence. ECB outcomes were neither as good as those matched nor as bad as those mismatched to the different exposures of relationship enhancement. This suggests that dose of relationship enhancement should be determined after assessing patient relationships.

Changes in family functioning during treatment and drinking outcomes for high and low autonomy alcoholics.

Alcoholics' level of autonomy was hypothesized to have a moderating effect on the relationship between changes in family functioning and subsequent drinking behavior. Functioning of families of patients in outpatient alcoholism treatment was assessed prior to the onset of treatment and again 6 months later. For alcoholics who were low in autonomy, perceptions of improvements in functioning predicted better drinking outcomes during a subsequent 6-month follow-up, while changes in family functioning were unrelated to drinking behavior in high autonomy alcoholics. The areas of family functioning in which change was a significant predictor of later drinking primarily concerned the quality of interactions between family members. Alcoholics' gender, psychiatric comorbidity, and the type of treatment they received did not moderate the relationship between changes in family functioning and drinking outcomes. Implications for the treatment of alcoholic patients and the limitations of the research are discussed.

Effect of the social environment on alcohol involvement and subjective well-being prior to alcoholism treatment.

This article describes a conceptual model developed to explain abusive use of alcohol and reports results of an initial test of that conceptualization. General social support is hypothesized to affect the level of subjective well-being, while alcohol-relevant social support affects the degree of alcohol involvement. A cross-sectional test of two models derived from this formulation was made using data from 148 alcoholic clients entering treatment at a private non-profit psychiatric facility. Results indicate that a model in which no direct relationship between alcohol involvement and subjective well-being is specified provides a more parsimonious explanation of interrelationships at the time of treatment entry. Alcohol involvement is explained by alcohol-relevant affiliative and instrumental support (albeit weakly), and subjective well-being is explained by general affiliative and instrumental social support. There is virtually no interrelationship between alcohol involvement and subjective well-being once the support variables are taken into account. The findings indicate that treatment should more often incorporate others from a client's social network, using significant others first to provide general social support and later alcohol-relevant support as well. Further analyses involving samples with more heterogeneity in levels of social investment and exploring the utility of these variables for treatment matching categorization decisions are warranted.

Differences between alcoholics and spouses in their perceptions of family functioning.

The present study is an investigation of differences between alcoholics and significant others in their perceptions of the functioning of their families or households. A sample of 80 pairs of alcoholic patients (PTs) and their spouses or spouse equivalents (SOs) who were living together in the same household evaluated family functioning by completing the Family Assessment Device (FAD). Agreement between PTs and SOs was moderate on the Affective Responsiveness, Communication, Problem Solving, Roles, and General Functioning scales. However, there was little or no agreement on the Behavior Control and Affective Involvement scales. These results indicate that although PTs and SOs tended to agree about how well family members work together and share thoughts and feelings, they disagreed about how well boundary issues were dealt with in their families. Implications for treating alcoholic families are discussed.

Does adding conjoint therapy to individually focused alcoholism treatment lead to better family functioning?

This report examines functioning in the families of alcoholics undergoing outpatient treatment. Alcoholic patients were randomly assigned to two social-learning-based alcoholism treatments, one of which contained a conjoint therapy component. Patients (Pts) and significant others (SOs) provided ratings of family functioning before treatment and at a 6-month follow-up. According to the perceptions of both Pts and SOs, there were significant improvements in family functioning in a number of areas at posttreatment. Contrary to what was expected, however, the improvements were not greater in the conjoint condition. The usefulness of alcoholics' level of autonomy as a matching variable also was explored. According to the perceptions of both Pts and SOs, posttreatment family functioning was better when low-autonomy alcoholics were treated without other family members. There also was evidence that conjoint treatment was more effective with high-autonomy alcoholics and their families, although it was less convincing and limited to the SOs' perceptions. Implications for alcoholism treatment and the limitations of the findings are discussed.

Assessment of alcohol-related workplace activities: development and testing of "Your Workplace".

Alcohol-related workplace activities are assessed using a short, easy to administer, self-report instrument. Three scales--Adverse Effects of Drinking on Work Performance, Support for Consumption and Support for Abstinence--are derived from it. They have internal reliability, are independent of one another and have face validity as well as discriminant and convergent validities. Some evidence of predictive (criterion-related) validity is presented. Researchers seeking to assess the interrelationship between alcohol-related work factors and drinking behavior can apply this instrument to the task.

The relationship of pretreatment family functioning to drinking behavior during follow-up by alcoholic patients.

The relationship of alcoholics' perceptions of the pretreatment functioning of their families to drinking outcomes during an 18-month follow-up was examined. Family functioning was hypothesized to be predictive of drinking behavior, particularly in subjects with low assertion of autonomy scores. These individuals report greater dependency and attachment, and therefore might be more affected by the state of important relationships. The results indicated that with low autonomy male alcoholics, greater family dysfunction predicted significantly fewer days abstinent during Months 1-6 and 13-18 and more severe drinking episodes during the first year of the follow-up. In the high autonomy males, family dysfunction was unrelated to subsequent drinking behavior. In women, on the other hand, greater family dysfunction predicted more days abstinent in those high in autonomy and was unrelated to the drinking behavior of those low in autonomy. Implications for patient-treatment matching, differences between male and female alcoholics, and the need for additional studies of family functioning and drinking behavior in women are discussed.

Liver function tests and neuropsychologic impairment in substance abusers.

The relationship between residual neuropsychologic dysfunction in alcoholics and subtle changes in liver function during acute phases of treatment was examined. Noncirrhotic alcoholics who exhibited extreme elevations in the liver enzyme gamma-glutamyl transferase (GGT) were found to have greater impairments in tasks of visuoperceptual and conceptual abilities when compared to alcoholics with normal or only mild elevations in GGT. The relationship between acute liver dysfunction and residual neuropsychologic impairment appeared to be independent of age and patterns of drinking. The implications of these findings in relation to treatment planning and prognosis of alcoholics are discussed.

An outcome monitoring system for psychiatric inpatient care.

As the national impetus for examining treatment outcomes increases, the demand for cost-effective systems for psychiatric outcome monitoring grows. This article describes one local effort to develop a monitoring system at Butler Hospital in Providence, Rhode Island. The system uses a combination of face-to-face and computer interviews of a random sample of recently admitted inpatients, with follow-up interviews one month postdischarge and one year following admission. The patient self-report data and interviewer assessment data generated by these interviews are used to quantify patient symptoms and social functioning. With a large enough sample, these findings can be used to identify areas where patient care may be improved. The article also discusses the process and problems involved in implementing the monitoring system and presents illustrative preliminary findings.