Reductions in physical pain predict lower risk of relapse following alcohol treatment.

OBJECTIVE: Physical pain is considered a potential predictor of relapse in alcohol-dependent individuals after treatment. The aim of this study was to evaluate whether reductions in pain level during the follow-up period after treatment were associated with lower relapse risk. METHOD: A sample of 366 participants was recruited from alcohol treatment centers in Warsaw, Poland. At baseline, information was obtained about pain level, demographics, childhood abuse, impulsivity, depressive symptoms, severity of alcohol and sleep problems. After finishing the alcohol treatment program, patients were followed for 12 months and alcohol drinking (relapse) as well as pain severity were evaluated. RESULTS: In the followed-up group, 29.5% of patients confirmed that they drank any alcohol during past 4 weeks. Comparing follow-up to baseline pain, 48.6% of subjects reported an increased severity of pain, 28.8% reported the same level of pain, 22.6% reported decreased level of pain. There was a significant association between the decrease in level of pain and the lower risk of relapse. Other factors associated with relapse during 4 weeks prior to the follow-up were baseline severity of depressive symptoms, low baseline social support and number of drinking days during 4 weeks prior to entering treatment. In multivariate analysis, a decrease in pain level was associated with a lower likelihood of relapse (OR=0.159; 95%CI:0.04-0.62; p=0.008) even when controlled for other factors associated with relapse. CONCLUSIONS: Decreases in pain level following treatment for alcohol dependence are associated with, and may contribute to, a lower risk of alcohol relapse.

Correlates of violence history among injured patients in an urban emergency department: gender, substance use, and depression.

This study surveyed consecutive injured patients (n = 320) in an urban emergency department (ED) regarding past year violence, substance use, and depression. Victimization and aggression variables (none = N, partner only = P, non-partner only = NP, and generalized/both partner and non-partner = G) were compared on gender, depression, and substance use/consequences. Findings were similar for victimization and aggression variables. Depression was significantly related to violence for women but not for men; women in the P group reported the most depression. Substance variables were significantly related to violence by gender groups. Men in NP and G groups reported the most binge drinking; men in the G group reported the most consequences and drug use. Women in P and G groups reported the most binge drinking and consequences; women in the P group reported the most drug use. Screening urban ED patients for violence is warranted, with interventions addressing both partner and non-partner violence.

Adherence assessments and the use of depot antipsychotics in patients with schizophrenia.

BACKGROUND: Antipsychotic medications significantly ameliorate the symptoms of schizophrenia, but patients are often noncompliant with these medications. Research evidence supports the use of depot antipsychotics in noncompliant patients. METHOD: Between January 9, 1991, and December 19, 1995, 1307 veterans with schizophrenia or schizoaffective disorder (ICD-9) were enrolled in a study of enhanced psychosocial programming at 14 Veterans Administration Medical Centers. All had a history of high inpatient use. At enrollment, clinicians listed patient medications, rated patient compliance, and completed a Brief Psychiatric Rating Scale (BPRS) and Global Assessment of Functioning (GAF). Patients reported medication side effects. We describe depot antipsychotic use among these patients and examine the relationship between depot use, assessed compliance, and patient characteristics. RESULTS: At enrollment, 18% of patients in this cohort were receiving depot antipsychotics; however, clinicians reported that 49% had been noncompliant with medication in the past year. Depot use varied significantly with treatment site; African Americans were more likely to receive depot antipsychotics and less likely to receive atypical antipsychotics than white patients. Patients on depot and oral agents had similar levels of psychiatric symptoms, but patients on depot antipsychotics were more likely to receive high doses and complain of side effects. CONCLUSION: Clinicians prescribed depot antipsychotics relatively infrequently, despite high rates of noncompliance and high levels of inpatient use. Variation in use with treatment site and ethnic group suggests barriers to implementing research-based recommendations for depot use in noncompliant patients. Quality improvement programs should consider facilitating the appropriate use of depots.

Diversity in relapse prevention needs: gender and race comparisons among substance abuse treatment patients.

Attempts to address high relapse rates following substance abuse treatment have focused on identifying relapse prevention needs and development of subsequent relapse prevention programs. Few studies have examined whether women and African-Americans have unique relapse prevention needs. Research in this area could provide an initial basis for the development of alternative relapse prevention approaches that could be more appropriate for this pop ulation. This study examined gender and race differences in psychosocial concerns among patients recruited from substance abuse treatment as potential indicators of relapse prevention needs. Participants (N = 331) completed several questionnaires during their first month of substance abuse treatment. Assessment packets included measures of coping, self-efficacy, resource needs, cravings, social influences, exposure, and leisure activities. Analyses focused on gender and race differences in these variables before and after controlling for background characteristics (i.e., age, marital status, income, polysubstance use, treatment type, and problem severity). Gender differences found were that men reported poorer coping skills and more negative social influences and exposure to substances than women; these differences remained significant when controlling for background characteristics. Significant race differences were found on all scales except negative social influences. After controlling for background characteristics, African-Americans reported significantly greater coping skills and self-efficacy than did Caucasians; however, African-Americans also reported greater resource needs in comparison to Caucasians. Results highlight the diversity in psychosocial issues among substance abusers in treatment, particularly between Caucasians and African-Americans. Implications for developing alternative relapse prevention approaches to address this diversity are discussed.

Correlates of expressed and received violence across relationship types among men and women substance abusers.

This study examined expressed and received violence among men and women in substance abuse treatment. Rates of past-year partner violence (PV) did not differ by gender, although men reported markedly higher rates of nonpartner violence (NPV). Compared with PV, NPV was associated with more demographic and background factors (e.g., childhood aggression and conduct problems, family history of violence). The most consistent correlates of violence across relationship types were age, minority status, drug-related consequences, psychiatric distress, and frequency of childhood aggression. Only a few gender-specific correlates were identified; most notably, witnessing father-to-mother violence was related to received PV only for women. Identification of correlates of expressed and received violence in partner and nonpartner relationships is essential for the assessment and treatment of individuals in substance abuse treatment settings.

Persistence of impaired functioning and psychological distress after medical hospitalization for men with co-occurring psychiatric and substance use disorders.

OBJECTIVE: To measure the persistence of impaired health-related quality of life (HRQL) and psychological distress associated with co-occurring psychiatric and substance use disorders in a longitudinal sample of medically hospitalized male veterans. DESIGN: A random sample followed observationally for 1 year after study enrollment. SETTING: Inpatient medical and surgical wards at 3 university-affiliated Department of Veterans Affairs Medical Centers. PATIENTS/PARTICIPANTS: A random sample of 1,007 admissions to medical and surgical inpatient services, excluding women and admissions for psychiatric reasons. A subset of participants (n = 736) was designated for longitudinal follow-up assessments at 3 and 12 months after study enrollment. This subset was selected to include all possible participants with study-administered psychiatric diagnoses (52%) frequency-matched by date of study enrollment to approximately equivalent numbers of participants without psychiatric diagnoses (48%). MEASUREMENTS AND MAIN RESULTS: All participants were administered a computerized structured psychiatric diagnostic interview for 13 psychiatric (include substance use) disorders and received longitudinal assessments at 3 and 12months on a multidimensional measure of HRQL, the SF-36, and a measure of psychological distress, the Symptom Checklist, 90-item version. On average, HRQL declined and psychological distress increased over time (P <.05). Psychiatric disorders were associated with significantly greater impairments in functioning and increased distress on all measures (P <.001) except physical functioning (P <.05). These results were replicated in the patients (n = 130) who received inpatient or outpatient mental health or substance abuse services. CONCLUSIONS: General medical physicians need to evaluate the mental health status of their hospitalized and seriously ill patients. Effective mental health interventions can be initiated posthospitalization, either immediately in primary care or through referral to appropriate specialty care, and should improve health functioning over time.

Race, psychiatric diagnosis, and mental health care utilization in older patients.

To evaluate the impact of race on mental health care utilization among older patients within given clinical psychiatric diagnoses, the authors examined a retrospective sample of 23,718 elderly veterans treated in Department of Veterans Affairs inpatient facilities in 1994. Significant racial differences in mental health care utilization found over a subsequent 2-year period were related to outpatient (but not inpatient) care; for instance: 1) African American patients with psychotic disorders had significantly fewer outpatient psychiatric visits; and 2) African American patients with substance abuse disorders had significantly more psychiatric visits than Caucasian patients in their respective groups. Although inpatient utilization appeared to be similar among races, findings related to outpatient utilization may be associated with such factors as compliance, treatment efficacy, access to health care, or possible clinician bias.

Older patients with at-risk and problem drinking patterns: new developments in brief interventions.

The relationship between alcohol and some of the most prevalent physical and mental health issues of older adulthood and the fact that a large percentage (up to 60% in randomized clinical trials) of older at-risk drinkers may need either more intense or innovative approaches to help them cut down or stop drinking have led to new developments in alcohol screening and brief interventions with older adults. Technological and content innovations are critical elements in providing rapid, effective interventions with a spectrum of alcohol use problems in later adulthood. Both primary and specialty care providers can be trained to provide motivational brief alcohol interventions targeted to the older patient. Novel approaches to screening, brief interventions, and brief therapies can be combined with the use of new technologies to facilitate implementation in a range of health care settings. This will give mental health specialty providers additional strategies for addressing the complex needs of older at-risk drinkers using a family of efficient and effective approaches.

Treatment of older women with alcohol problems: meeting the challenge for a special population.

As a larger proportion of the U.S. population reaches late life, there are new challenges to providing quality health care services for this group. Record numbers of adults over 60 are seeking health care for acute and chronic conditions. Older women represent the largest single group of health care users in this country. Twelve percent of older women regularly drink in excess of recommended guidelines (no more than one drink per day or seven drinks per week) and can be considered at-risk drinkers. Problems related to alcohol use and misuse can seriously affect many of the health concerns common among older women, including chronic illnesses and depression. Older women have specific risks and vulnerabilities to alcohol use, which include a swifter progression to alcohol-related illness. However, women in later life who have alcohol problems are underscreened and underdiagnosed, have significant barriers in accessing health care, and respond differentially to standard specialized treatment protocols. To date, research on these topics has been limited. Furthermore, there is a paucity of research focused on treatment outcomes for elderly adults with alcohol problems, with almost no emphasis on women. This paper presents the state of knowledge about alcohol health services for older women and provides recommendations for necessary future health services research on this vulnerable population.

Targeting quality improvement activities for depression. Implications of using administrative data.

BACKGROUND: Large health care organizations may use administrative data to target primary care patients with depression for quality improvement (QI) activities. However, little is known about the patients who would be identified by these data or the types of QI activities they might need. We describe the clinical characteristics and outcomes of patients identified through administrative data in 2 family practice clinics. METHODS: Patients with depression aged 18 to 65 years were identified through review of encounter/administrative data during a 16-month period. Patients agreeing to participate (N=103) were interviewed with the Primary Care Evaluation of Mental Disorders questionnaire and completed the Depression Outcomes Modules (with an embedded Medical Outcomes Short Form-36 [SF-36]), Symptom Check List-25 (SCL-25), and Alcohol use Disorders Identification Test. Follow-up assessments were completed by 83 patients at a median of 7 months. RESULTS: A large majority of identified patients (85%) met full criteria for a Diagnostic and Statistical Manual of Mental Disorders depressive disorder; those not meeting criteria usually had high levels of symptoms on the SCL-25. Seventy-seven percent of the patients reported recurrent episodes of depressed mood, and 60% reported chronic depression. Although most improved at follow-up, they continued to have substantial functional deficits on the SF-36, and 60% still had high levels of depressive symptoms. CONCLUSIONS: QI programs that use administrative data to identify primary care patients with depression will select a cohort with relatively severe, recurrent depressive disorders. Most of these patients will receive standard treatments without QI interventions and will continue to be symptomatic. QI programs targeting this population may need to offer intensive alternatives rather than monitor standard care.

Effectiveness of specialized treatment programs for veterans with serious and persistent mental illness: a three-year follow-up.

This is the first study to test concurrently the effectiveness of four treatment programs for patients with serious mental illness. Three-year outcome data on utilization and functioning demonstrated important positive changes for seriously mentally ill veterans enrolled in specialized, enhanced inpatient and community case management treatment programs, when compared to patients in an enhanced day treatment program or traditional standard care.

A comparison of substance abuse patients' and counselors' perceptions of relapse risk: relationship to actual relapse.

This study compared substance abuse patients' and their counselors' perceptions of relapse risk during treatment and evaluated whether these perceptions predict actual relapse 2 years later. Participants (N = 240) completed the Relapse Risk Index (RRI), which assesses confidence in abilities and need for services across four domains: coping skills, social support, resources, and leisure activities. Participants reported greater confidence and greater needs than counselors reported. Determinants of counselors' relapse risk perceptions included income, whereas participants' perceptions were related to polysubstance use. Counselors' ratings of coping skills predicted alcohol relapse; counselors' ratings did not predict drug relapse. Participants' ratings of coping skills and leisure activities predicted alcohol relapse; social support predicted drug relapse. When including background characteristics, counselors' ratings did not predict alcohol or drug relapse; participants' ratings predicted alcohol relapse but not drug relapse. Findings suggest the potential utility of considering patient perceptions to understand and possibly prevent relapse.

Age-group differences in treatment outcomes for male veterans with severe schizophrenia: a three-year longitudinal study.

Treatment outcomes in later-life schizophrenia are poorly understood and of serious concern for clinicians and mental health policy makers. Age-group differences were examined for 499 male veterans with severe schizophrenia enrolled in enhanced treatment programs at 12 Veterans Affairs hospitals. Participants were separated into three age groups (20-39 years, 40-59 years, 60 years and above), with the following outcomes assessed at enrolment and 1 and 3 years afterwards: psychiatric symptomatology, global functioning, impairment in Instrumental Activities of Daily Living (IADL), and hospital use. All three age groups experienced significant improvement in psychiatric symptoms over time. The oldest group fared worse than younger patients in terms of global functioning and generally required more inpatient services and assistance with IADL. Innovative programming is needed to meet the special needs of the growing population of older adults with schizophrenia.

The relationship between alcohol problems and health functioning of older adults in primary care settings.

OBJECTIVE: The purpose of this study was to determine the relationship between alcohol use and health functioning in a sample of older adults screened in primary care settings. DESIGN: A cross-sectional study. SETTING: Thirty-seven primary care clinics. PARTICIPANTS: Older adults (n = 8,578; aged 55-97) with regularly scheduled appointments in primary care clinics were screened. MEASUREMENTS: Participants were categorized based on alcohol consumption levels as abstainers, low-risk drinkers, and at-risk drinkers (women: 9 or more drinks/week; men: 12 or more drinks/week). Dependent variables were eight SF-36 health functioning scales. RESULTS: Sixty-one percent of participants were abstainers, 31% were low-risk drinkers, and 7% were at-risk drinkers. ANCOVAs found significant effects of drinking status on General Health, Physical Functioning, Physical Role Functioning, Bodily Pain, Vitality, Mental Health, Emotional Role, and Social Functioning, controlling for age and gender, with low-risk drinkers scoring significantly better than abstainers. At-risk drinkers had significantly poorer mental health functioning than low-risk drinkers. Few significant gender differences were found on SF-36 scales. CONCLUSIONS: Older adults who are at-risk drinkers may not present with poor physical health functioning. Future studies are needed to determine the relationship between drinking limits for older adults and other areas of physical and psychosocial health.

Older adult treatment outcome following elder-specific inpatient alcoholism treatment.

This study examined multidimensional 6-month outcomes of elder-specific inpatient alcoholism treatment for 90 participants over the age of 55. At baseline, physical health functioning was similar to that reported by seriously medically ill inpatients in other studies while psychosocial functioning was worse, and nearly one third of the sample had comorbid psychiatric disorders. Based on 6-month outcomes, participants were classified into the following groups: Abstainers, Non-Binge Drinkers, and Binge Drinkers. The groups did not differ on any baseline measures (demographics, drinking history, alcohol symptoms and age of onset, comorbidity, or length of treatment). General health improved between baseline and follow-up for all groups. Psychological distress decreased for Abstainers and Non-Binge Drinkers, but did not change for Binge Drinkers. Results suggest that a large percentage of older adults who receive elder-specific treatment attain positive outcomes across a range of outcome measures.

Race and inpatient psychiatric diagnoses among elderly veterans.

OBJECTIVE: Limited data exist on differential rates of psychiatric diagnoses between ethnocultural groups in the elderly population. The purpose of this study was to examine more closely the issue of race and rates of psychiatric diagnoses among elderly inpatients. METHODS: The national sample included 23,758 veterans age 60 or over admitted in 1994 to acute inpatient units in Department of Veterans Affairs (VA) hospitals. Psychiatric diagnosis determined inclusion in one of six diagnostic groups: cognitive, mood, psychotic, substance use, anxiety, and other disorders. The study also assessed rates of psychiatric diagnoses among patients admitted to psychiatric units only and by age group and treatment setting, such as the size of the hospital and whether it had an academic affiliation. RESULTS: Compared with elderly Hispanic and Caucasian patients, a significantly higher proportion of elderly African-American patients were diagnosed as having cognitive disorders and substance use disorders, and a significantly lower proportion were diagnosed as having mood and anxiety disorders. Hispanic and African-American patients had significantly higher rates of psychotic diagnoses than Caucasian patients. For all diagnoses except cognitive disorders, these differential rates were also found among patients admitted to psychiatric units only. Age and treatment setting appeared to moderate some of the differences in diagnostic rates, except for mood disorders. In every analysis performed, the rate of mood disorder diagnoses among elderly African-American patients was less than half the rate among elderly Caucasian patients. CONCLUSIONS: The findings suggest that elderly African-American veterans admitted to VA inpatient units have strikingly lower rates of mood disorder diagnoses. Future studies should examine the contribution of both patient and provider factors to these differences.

Emergency physician attitudes concerning intervention for alcohol abuse/dependence delivered in the emergency department: a brief report.

Emergency Medicine (EM) physicians frequently see patients with alcohol abuse or dependence (AA/AD). Brief interventions delivered in the Emergency Department (ED) have been advocated for these patients, however, little is known regarding EM physician willingness to support such interventions. We conducted a study to determine EM physicians' attitudes toward the use of interventions for AA/AD in the ED. All members of the Michigan College of Emergency Physicians (n = 569) were mailed a survey to assess their attitudes toward the use of intervention for AA/AD in the ED. Of the 257 respondents (45.9%), a total of 76% agreed that AA/AD is a treatable illness and only 15% would not agree to support of ED interventions. Both supporters and non-supporters thought that the lack of sufficient time was an impediment to treating AA/AD in the ED. Our study suggests that the majority of ED physicians would support the implementation of brief intervention for AA/AD in the ED.

Stability in the drinking habits of older problem-drinkers recruited from nontreatment settings.

Few prospective studies have examined older problem-drinkers not currently in treatment to determine the stability in alcohol problems over time. Seventy-eight currently drinking, older adults meeting a diagnosis of alcohol abuse or dependence were recruited via advertising to complete a health interview; 48 were reinterviewed approximately 3 years later. Participants were categorized based on alcohol consumption (risk) and alcohol-related diagnostic symptoms (problem) at baseline and follow-up. At follow-up, few older adults (11.4%) were resolved using both risk and problem criteria. Alcohol risk/problem groups were not significantly stable between baseline and follow-up. Health problems was the most common reason for changing drinking habits. Average and maximum consumption at baseline and follow-up were significant markers of follow-up risk group and follow-up alcohol-related consequences, respectively, with maximum consumption being more robust. The course of alcohol problems among older adults fluctuates over time, and heavy drinking appears to be the best indicator of problem continuation.

Adolescent injury in the emergency department: opportunity for alcohol interventions?

STUDY OBJECTIVE: Alcohol, the most commonly used substance among adolescents, is frequently associated with injury. Little is known regarding the drinking characteristics of injured adolescents. Such data are critical for developing emergency department interventions to decrease alcohol-related injury among adolescents. We sought to describe the drinking characteristics of injured adolescents and to describe the relationship of injury severity and mechanisms with drinking characteristics. METHODS: This study was a prospective cohort study performed in a university hospital (sampled May 1, 1995, to July 15, 1995) and a large urban teaching hospital (sampled May 1, 1996, to August 1, 1996). The participants were aged 12 to 20 years, presenting within 6 hours of an injury. We performed a saliva alcohol test and self-administered questionnaire. Age, sex, E-code, injury severity score (ISS), and ED disposition were recorded. An alcohol frequency/quantity index was calculated. Descriptive statistics and 95% confidence intervals were calculated. RESULTS: Two hundred sixty-three patients with a mean age of 17 years and a mean ISS of 2.1 (SD 3.5) were recruited. One hundred fifty-two (50%) were males, and 33 (13%) were admitted. Ten (4%) patients had a positive saliva alcohol test response. On average, within the last year, these adolescents had 1.7 adverse alcohol consequences. Sixty percent drank in unsupervised settings, and 36% reported drinking 5 or more drinks in a row. CONCLUSION: Alcohol use/misuse is a substantial problem among injured adolescents regardless of severity or mechanism of injury. ED physicians should consider screening/intervention or primary prevention of alcohol problems for all injured adolescents.