Missed opportunities in addressing drinking behavior in medical and mental health services

BACKGROUND: Epidemiological and clinical literature point to the importance of screening for alcohol problems in medical and psychiatric settings. However, little is known about which problem drinkers seek help from those services or about the characteristics of those who have their drinking addressed. METHODS: We interviewed a probability sample of adult dependent and problem drinkers in the general population (n = 672) and consecutive admissions to chemical dependency programs in a northern California county (n = 926). We reinterviewed them 1 year later and measured medical and mental health visits and whether their drinking was addressed during the visit. RESULTS: Almost two-thirds of problem drinkers had a medical visit, and approximately one-third had a mental health visit, yet drinking was not often discussed, especially during medical visits. Many of those more likely to have a visit were not more likely to have their drinking addressed. Women and individuals older than 40 years had more medical and mental health visits [odds ratio (OR), 1.71; p < 0.001 and OR, 1.55; p < 0.001, respectively, for women; OR, 1.57; p < 0.05 and OR, 1.64; p < 0.05, respectively, for age >/=40 years], but were not more likely to have their drinking addressed in either setting, and women were less likely than men to have their drinking addressed in mental health settings (OR, 0.62; p < 0.05). Those with higher alcohol severity and those who had attended chemical dependency treatment during the previous year were more likely to have their drinking addressed in each setting. Insurance status predicted medical, but not mental health, visits and was not related to having drinking addressed in either setting. CONCLUSIONS: Drinking behavior was not routinely addressed by medical and mental health practitioners for dependent and problem-drinking men and women who presented in public and private medical and mental health settings.     

Inpatient substance abuse care and the outcome of subsequent community residential and outpatient care

Aim. To compare participation in treatment and 1-year substance use, symptom and functioning outcomes between patients with substance use disorders who did versus those who did not have an episode of inpatient care immediately prior to an episode of community residential and outpatient mental health care. Design. Two matched groups of 257 patients each with substance use disorders were assessed at entry to and discharge from a community residential facility (CRF) and at a 1-year follow-up. Findings. Patients in the two treatment groups received a comparable amount of CRF and outpatient mental health care. Nevertheless, patients who had prior inpatient care were more likely to be employed at 1-year follow-up. In addition, when they entered CRF care directly, patients with co-morbid psychiatric disorders were more likely to continue use of alcohol and drugs in the CRF and less likely to complete the program. These patients also experienced more distress and psychiatric symptoms, and were less likely to be employed at the 1-year follow-up. Conclusions. Among patients who seek treatment at Department of Veterans Affairs (VA) facilities, those who have both substance use and psychiatric disorders and enter CRF care directly have somewhat worse outcomes than those who have an immediately prior episode of inpatient care.     

A Complex Relationship Between Co‐occurring Social Anxiety and Alcohol Use Disorders: What Effect Does Treating Social Anxiety Have on Drinking?

Background: Individuals with social anxiety disorder and co‐occurring alcohol problems report using alcohol to cope with anxiety symptoms. Interventions that reduce both social anxiety and drinking are needed. Paroxetine, an FDA‐approved medication to treat social anxiety disorder, reduces anxiety in individuals with co‐occurring alcohol problems. Objectives: To examine whether effective treatment of social anxiety with paroxetine reduces drinking in dual‐diagnosed individuals who endorse using alcohol to cope. Methods: A 16‐week, double‐blind, randomized controlled trial of paroxetine was conducted. Participants (placebo n = 22; paroxetine n = 20) met DSM‐IV diagnostic criteria for social anxiety disorder and alcohol abuse or dependence. Participants were seeking treatment for social anxiety, not for the alcohol problem. Alcohol use outcomes were measured with conventional quantity/frequency measures and novel measures of drinking to cope. Results: Paroxetine improved social anxiety more than placebo. Paroxetine reduced self‐reported reliance on alcohol for self‐medication purposes, but was not different than placebo in changing quantity and frequency drinking or the proportion of drinking days that were identified as coping‐related. Exploratory analyses revealed that for the placebo group, drinking during the trial was correlated with social anxiety severity, whereas for the paroxetine‐treated group, drinking was uncoupled from social anxiety severity. Conclusions: Successfully treating social anxiety symptoms with paroxetine does not reduce drinking in dual‐diagnosed individuals who are not seeking treatment for alcohol problems. Paroxetine does, however, reduce reliance on alcohol to engage in social situations, and may change the reasons why one drinks (such that drinking occurs for other reasons besides coping with anxiety). These results have implications for staging of social anxiety and alcohol treatment in individuals with the co‐occurring disorders presenting to a mental health or primary care provider.     

Patterns in the institutional encounters of problem drinkers in a community human services network

It is useful to view the social handling of alcohol problems in US communities from the perspective of a whole network of human service systems that share in the burden of identifying and responding to problem drinkers. This analysis examines the management of alcohol problems in different community service systems by mapping patterns in the institutional encounters of problem drinkers across alcohol treatment, drug treatment, mental health treatment, social welfare and criminal justice systems in a single US community. Findings highlight the prominence of large bureaucratic systems for social welfare and criminal justice as sources of referrals for smaller service systems offering treatment for alcohol problems. However, large proportions of problem-drinking service recipients in the community remain exclusive clients of the welfare and criminal justice systems, making no contact with therapeutically orientated service settings. Compared with problem drinkers who obtain treatment services, problem drinkers on the case-loads of criminal justice and welfare agencies tend to be younger, of higher socio-economic status, are more likely to be male, and tend to drink less heavily and to experience fewer symptoms of alcohol dependence. Given the distinctive characteristics of problem drinkers found exclusively in criminal justice and welfare settings, it may be advisable for communities to introduce early intervention programs in these systems that target services to this particular subgroup of problem drinkers.     

Relationship of Binge Drinking to Alcohol Dependence, Other Psychiatric Disorders, and Behavioral Problems in an American Indian Tribe

The hypothesis that binge drinking is a benign behavior not associated with alcohol dependence, other psychiatric disorders, or problem areas, in American Indians, was tested in a sample of 582 adult Southwestern American Indian males and females in large multigenerational pedigrees. All information was obtained from semistructured psychiatric interviews that were independently blind-rated for DSM-III-R diagnoses. Three main outcome measures were used: the relationship between binge drinking and (1) alcohol dependence and other psychiatric disorders, (2) substance abuse treatment, and (3) four behavioral problem categories-violence/lawlessness, physical, social, and work. Binge drinking and alcohol dependence were strongly associated. Most binge drinkers were diagnosed as alcohol dependent. However, when controlling for alcohol dependence and other covariates, binge drinking was independently associated with an increase in odds for positive diagnoses for multiple psychiatric disorders, and for social, work, physical, and violence/lawlessness behavioral problems. In sum, binge drinking was found to be a common and severe problem with deleterious consequences in multiple domains of functioning. Assessment instruments should be designed to elicit information on binge patterns of drinking and strategies devised to provide appropriate treatment.     

Life-time problem drinking and psychiatric co-morbidity among Ontario women 1

Women problem drinkers in the community, aged 15-64 years, with and without life-time psychiatric co-morbidity were compared to examine the association of this co-morbidity with alcohol consumption patterns, course and chronicity of problem drinking, treatment service utilization and other substance use and misuse. The women problem drinkers were also compared with non-problem drinkers on substance use patterns and utilization of services. The study employs data from the Mental Health Supplement to the Ontario Health Survey, a province-wide household population study. The University of Michigan Composite International Diagnostic Interview (UM-CIDI) was administered by trained lay interviewers and subsequently World Health Organization computer algorithms were used to generate DSM-III-R diagnoses based on the interview responses. Multiple logistic regression analysis indicated that psychiatric co-morbidity was associated with less education, earlier onset of problem drinking and one indicator of binge drinking. Co-morbidity also greatly increased the chances of women problem drinkers having sought mental health treatment. Women problem drinkers were significantly younger (about 7 years) than other women in the general population, perhaps an indicator of an increased mortality rate.     

Relationships between Socioeconomic Status and Drinking Problems among Black and White Men

We sought to examine the relationships between socioeconomic status and drinking problems within the Black and White male populations. A two-way interaction of social class with race/ethnicity, and with drinking consequences and alcohol dependence symptoms was hypothesized among drinkers. Drinking problems were regressed on social class, race/ethnicity, age, alcohol consumption, and drinking settings. Social class was based on a composite of respondent's income, education, and main wage earner's occupation. Two types of drinking problems were analyzed: drinking consequences and alcohol dependence symptoms. Our hypothesis was partially confirmed. Interactions of social class with race/ethnicity and with drinking problems were observed. Less affluent Black men reported greater numbers of drinking consequences and total drinking problems than less affluent White men; the reverse was true for affluent Black and White men. Results suggest that the relationships between socioeconomic status and drinking problems may vary by race/ethnicity.     

Short-term processes of remission and nonremission among late-life problem drinkers.

This prospective study compares alcohol use, functioning, life stressors, social resources, and help-seeking among three groups of older adults: remitted problem drinkers, nonremitted problem drinkers, and nonproblem drinkers. At initial assessment, to-be-remitted problem drinkers had several advantages compared with individuals who would continue to have drinking problems. Specifically, they consumed less alcohol, reported fewer drinking problems, had friends who approved less of drinking, and were more likely to seek help from mental health practitioners. Problem drinkers who remitted improved somewhat over time, but they did not attain the level of functioning or type of life contexts shown by nonproblem drinkers. Time of onset of drinking problems influenced the short-term process of remission: Compared with early-onset individuals, late-onset problem drinkers were more likely to remit over the 1-year interval. The predictors of short-term remission suggested that late-onset problem drinkers may be more reactive to physical health stressors and to social influences than are individuals with more long-standing problems with alcohol.     

Community psychiatric nurse aftercare for alcoholics: a five-year follow-up study

The aim of this study was to determine if community psychiatric nurse (CPN) aftercare for 1 year improved the 5-year outcome in patients following inpatient treatment for alcohol dependence. A 5-year follow-up study, observer blind, with non-random allocation of subjects to aftercare by CPN for 1 year or standard outpatient care, was used. Subjects had all received inpatient treatment for 6 weeks in a rural alcohol treatment unit. Subjects were traced and assessed in the community 5 years after the index admission. The participants consisted of 127 white male alcoholics. All were first admissions, who had been selected for inpatient treatment and who completed a 6-week inpatient stay. Seventy-three subjects received intensive aftercare by CPN for 1 year, 54 subjects received standard outpatient appointments not due to random allocation but because no CPN was available. Data were collected by semi-structured interview at entry to the trial, namely background epidemiological information, details of drinking history, previous hospital admission, educational, employment and criminal information. At 5-year follow-up, data on drinking status, use of other drugs, hospital admissions, criminal behaviour and gambling, attendance at self-help groups, relationships and employment were collected. Thirty-six per cent of the CPN aftercare group was completely abstinent during the 5 years after treatment compared to 6% of the standard aftercare group (p 0.001). Subjects receiving CPN aftercare were less likely to report blackouts (p 0.05) or gambling (p 0.05). They were more likely to attend hospital meetings (p 0.0001). CPN aftercare is an effective way of maximizing the effects of inpatient treatment. The effects endured for 5 years after treatment.     

Assessing the Relationship Between Mental Health Symptoms and Alcohol Consequences in College Drinkers

College drinking is a public health dilemma affecting the nation’s institutions of higher education. This article assesses the relationship between mental health symptoms and alcohol consequences experienced by college drinkers. It is a secondary data analysis of the American College Health Association-National College Health Assessment (ACHA-NCHA II) Spring 2011 Executive Summary Data Set. The ACHA-NCHA II is a nationally recognized survey that supports colleges and universities in the data collection of their students’ mental, physical, and sexual health habits, behaviors, and perceptions of the campus wellness. A linear regression analysis test was used to test the relationship between the number of mental health symptoms and alcohol consequences. This article assesses whether male college students have more mental health symptoms when they experience alcohol consequences when compared to female college students. This study found female college students experience more mental health problem symptoms associated with alcohol consequences.     

Subdiagnostic alcohol use by depressed men and women seeking outpatient psychiatric services: consumption patterns and motivation to reduce drinking

Background: This study examined alcohol use patterns among men and women with depression seeking outpatient psychiatric treatment, including factors associated with recent heavy episodic drinking and motivation to reduce alcohol consumption. Methods: The sample consisted of 1,183 patients aged 18 and over who completed a self‐administered, computerized intake questionnaire and who scored ≥10 on the Beck Depression Inventory‐II (BDI‐II). Additional measures included current and past alcohol questions based on the Addiction Severity Index, heavy episodic drinking (≥5 drinks on 1 or more occasions in the past year), alcohol‐related problems on the Short Michigan Alcoholism Screening Test (SMAST), and motivation to reduce drinking using the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Results: Among those who consumed any alcohol in the past year (73.9% of the sample), heavy episodic drinking in the past year was reported by 47.5% of men and 32.5% of women. In logistic regression, prior‐year heavy episodic drinking was associated with younger age (p = 0.011), male gender (p = 0.001), and cigarette smoking (p = 0.002). Among patients reporting heavy episodic drinking, motivation to reduce alcohol consumption was associated with older age (p = 0.008), greater usual quantity of alcohol consumed (p < 0.001), and higher SMAST score (p < 0.001). Conclusions: In contrast to prior clinical studies, we examined subdiagnostic alcohol use and related problems among psychiatric outpatients with depression. Patients reporting greater drinking quantities and alcohol‐related problems also express more motivation to reduce drinking, providing intervention opportunities for mental health providers that should not be overlooked.     

How important is treatment? One‐year outcomes of treated and untreated alcohol‐dependent individuals

Aims To compare representative treatment and untreated samples of alcohol‐dependent individuals in rates of abstinence and non‐problematic use at 1‐year follow‐up. Participants and design A total of 482 alcohol‐dependent adults in a northern California county identified through a probability survey of problem drinkers in the general population (n = 111) or a survey of consecutive admissions to public and private substance abuse programs (n = 371) were interviewed in person at baseline and by telephone at 1 year. Measurements Logistic regression models were used to predict 30‐day abstinence and 12‐month non‐problematic alcohol use. Results At follow‐up, alcohol‐dependent individuals in the treatment sample had higher abstinence rates and non‐problematic use outcomes than those in the untreated general population sample. In logistic regression models of the merged samples, being in the treatment sample was related strongly and positively to abstinence and non‐problematic use. Having more drug users and heavy drinkers in one's social network, higher psychiatric comorbidity, and more social consequences were inversely related to abstinence and non‐problematic use in the treatment sample. The number of drug users and heavy drinkers in one's social network was also inversely related to abstinence in both the treatment and untreated general population samples. Results predicting non‐problematic use were similar. Conclusions These results are consistent with other studies that examine treatment effectiveness in the absence of a controlled trial. Although natural recovery also occurs, alcohol‐dependent individuals benefit from treatment. Co‐occurring psychiatric problems continue to be major barriers to treatment effectiveness. An emphasis on changing social networks to be conducive to recovery could heighten both clinical effectiveness and prevention efforts within communities.     

Functioning, life context, and help-seeking among late-onset problem drinkers: comparisons with nonproblem and early-onset problem drinkers

We compared the functioning and life contexts of late-middle-aged adults classified as late-onset problem drinkers (n=229), early-onset problem drinkers (n=475), and nonproblem drinkers (n=609). Compared with nonproblem drinkers, late-onset problem drinkers consumed more alcohol and functioned more poorly; they also reported more negative life events and chronic stressors, fewer social resources, and more use of avoidance coping. However, late-onset problem drinkers consumed less alcohol, had fewer drinking problems, functioned better, and had more benign life contexts than did early-onset problem drinkers. We found no evidence of an association between age-related loss events and the onset of late-life drinking problems. Very few problem drinkers sought help specifically for their alcohol abuse, but about 25% did seek treatment from mental health practitioners. Problem drinkers who were functioning more poorly and who reported more life stressors and fewer social resources were more likely to seek help.     

Patient and Provider Attitudes towards Monitored Naltrexone Treatment of Alcohol Dependence in Schizophrenia

Objective: To describe the attitudes of patients and their mental health providers regarding participation in a controlled trial of directly monitored naltrexone (NTX) treatment for alcohol dependence in schizophrenia. Method: Ninety participants with schizophrenia and their providers were asked to report opinions of treatment with oral NTX or placebo 3 times per week for 12 weeks, motivational counseling (MI), and voucher-based incentives (VBI) for attendance. Results: Seventy-nine percent of participants “liked the study a lot,” and 94% reported that it was helpful. Study components rated as helpful by participants were: VBI (95% of participants), meeting with staff 3 times per week (84%), reporting alcohol use (82%), MI (82%), reporting psychiatric symptoms (73%), breath alcohol testing (72%), and study medication (57%). Benefits reported by patients were: feeling better mentally (67%), drinking less (52%), feeling better physically (49%), and stopping drinking (27%). Seventy percent of providers reported that the study was helpful. Benefits noted by providers included: reduced drinking (33%), better treatment adherence (32%), stopping drinking (23%), and reduced psychiatric symptoms (22%). Patient/provider responses agreed on helpfulness with stopping or reducing drinking. Conclusions: Most participants with schizophrenia liked participating in a clinical trial of directly observed naltrexone treatment for alcohol dependence, and found incentives for attendance, frequent staff contact and monitoring of drinking, and motivational counseling to be the most helpful. Most participants reported improvement in mental health and reduced drinking. Mental health providers also reported that the study was helpful, but they did not describe the same degree of benefit as did patients.     

The Chinese drinking problem: a review of the literature and its implication in a cross-cultural study

Alcoholism as a problem has never been widely understood in Chinese society. The rarity of alcoholism in Chinese society may be due to marked sensitivity to alcohol, associated with high levels of acetaldehyde, in this population. In addition, sociocultural reasons such as alcoholic beverages generally being consumed only at parties and during mealtimes, strong social sanctions against drunkards and drunken behavior, and the presence of a strong Confucian moral ethic, have accounted for the drinking behavior of Chinese individuals. However, there is evidence that alcohol consumption and the prevalence of alcoholism have skyrocketed in the past 40 years in Taiwan. Social and cultural changes may be expected to affect the incidence and prevalence of alcoholism and other mental disorders in terms of changes in a traditional culture, and social integration-disintegration. Differences in methodology for case identification, and the fact that Chinese alcoholic patients do not seek psychiatric treatment primarily for drinking problems, are also considered to account for some of the discrepancy between the actual rate and the lower identified rate of alcoholism. It can also be speculated that the low rate of alcoholism in psychiatric settings depends largely on the attitudes of patients, their families, and the general public towards drinking problems. Hence, this paper will review the theories and compare epidemiologic data about drinking problems in Chinese individuals, and then point to areas for future research.     

Referral gridlock

BACKGROUND: Patients' barriers to mental health services are well documented and include social stigma, lack of adequate insurance coverage, and underdiagnosis by primary care physicians. Little is known, however, about challenges primary care physicians face arranging mental health referrals and hospitalizations. OBJECTIVE: To examine how practice setting and environment influence primary care physicians' ability to refer patients for medically necessary mental health services. DESIGN: Cross-sectional analysis using nationally representative survey data from the 1998 to 1999 Community Tracking Study physician survey. The overall survey response rate was 61%. PARTICIPANTS: A 1998 to 1999 telephone survey of 6586 primary care physicians. MEASUREMENTS: Primary care physicians' report of whether they could obtain medically necessary referrals to high-quality mental health specialists or psychiatric admissions. RESULTS: Overall, 54% of primary care physicians reported problems obtaining psychiatric hospital admissions, and 54% reported problems arranging outpatient mental health referrals. Primary care physicians practicing in staff and group model HMOs were much less apt to report difficulties than physicians in solo and small-group practices (P <.001). Reports of inadequate time with patients (P <.001) and smaller numbers of psychiatrists in a market area (P <.01) also were associated with problems obtaining mental health referrals. Pediatricians were more apt to report problems than general internists (P <.001). CONCLUSIONS: Primary care physicians face greater hurdles obtaining mental health services than other medical services. Primary care is an important entry point for mental health services, yet inadequate referral systems between medical and mental health services may be hampering access.     

Trauma history in African-American women living with HIV: effects on psychiatric symptom severity and religious coping

Women living with HIV (WLHIV) have rates of post-traumatic stress disorder (PTSD) up to 5 times higher than the general population. Individuals living with HIV and a concurrent diagnosis of PTSD have poorer HIV-related outcomes; however, the prevalence and impact of PTSD on African-American WLHIV seeking mental health treatment is unknown. The aim of this study is to examine the associations between PTSD symptoms with psychiatric symptom severity and psychological/religious coping strategies in African-American WLHIV who are seeking mental health treatment. This is a cross-sectional study of 235 African-American WLHIV attending an urban community mental health clinic. Bivariate analyses were conducted to evaluate associations between a PTSD symptoms scale (PSS ≥ 21 versus PSS < 21) and (1) psychiatric severity, (2) coping strategies, and (3) religious coping strategies. Thirty-six percent reported symptoms consistent with PTSD (PSS ≥ 21). These women were significantly more likely to have worse mental health symptoms and were more likely to employ negative psychological and religious coping strategies. On the contrary, women with a PSS < 21 reported relatively low levels of mental health symptoms and were more likely to rely on positive psychological and religious coping strategies. Over one-third of African-American WLHIV attending an outpatient mental health clinic had symptoms associated with PTSD. These symptoms were associated with worse mental health symptoms and utilization of dysfunctional religious and nonreligious coping strategies. Untreated PTSD in WLHIV predicts poorer HIV-related health outcomes and may negatively impact comorbid mental health outcomes. Screening for PTSD in WLHIV could identify a subset that would benefit from evidence-based PTSD-specific therapies in addition to mental health interventions already in place. PTSD-specific interventions for WLHIV with PTSD may improve outcomes, improve coping strategies, and allow for more effective treatment of comorbid mental health disorders.     

Psychiatric Symptoms in Alcoholics Attending Outpatient Treatment

The importance of psychiatric symptomatology for the treatment course of alcoholics was analyzed in a long-term outpatient treatment study. Seventy-two patients, 60 men and 12 women, were personally interviewed during treatment and after 3 years. Before treatment psychiatric symptoms were rated according to the Comprehensive Psychopathological Rating Scale (CPRS). Women had significantly higher scores than men. Men with many symptoms and women had more psychological benefits from drinking and a more impaired personality structure than men with few symptoms. Men with many symptoms also had a lower level of social functioning. The severity of abuse did not differ between the three groups. Men with many symptoms had a less favorable outcome between 25 and 36 months after start of treatment than men with few symptoms and women. Among men who completed treatment, those with many symptoms showed a less successful course after 6 months and during the 3rd year after start of treatment, while differences after 3 months and during later stages of treatment were less pronounced. It is suggested that before start of treatment a psychiatric evaluation should be performed including psychiatric diagnosis, personality analysis, and an assessment of psychological benefits from drinking.     

Primary Syndromes of Alcohol Abuse: Their Measurement and Correlates

A factor analysis of the Alcohol Use Inventory identified four major syndromes of alcohol abuse in a clinical sample of N = 274 individuals. The first factor, labelled Alcohol Dependence, was characterized by loss of behavioural control when drinking, alcohol withdrawal symptoms, repeated attempts to stop drinking, and a compulsive drinking style. This factor was correlated with chronic social debilitation and various aspects of psychopathology. Factor I provided empirical evidence for the alcohol dependence syndrome described by Edwards and Gross. The second factor, termed Perceived Benefits From Drinking, was defined by a sustained drinking style and belief that alcohol use facilitates social and mental functioning. A correlation with anxiety symptoms indicated that drinking may be used to cope with stressful situations, especially in social interactions. The third factor was Marital Discord and encompassed drinking problems that either instigated or resulted from marital difficulties. The fourth factor, Polydrug Abuse, was marked by the use of illicit drugs in conjunction with a gregarious style of drinking. High scorers on this factor tended to be younger, socially deviant and rebellious. The results from this study supported a quantitative, multiple syndrome conception of alcohol abuse. Individuals may be ordered along several dimensions according to their level of problem severity.