Clinician assessment of psychiatric comorbidity and alcoholism severity in adult alcoholic inpatients

Although psychiatric comorbidity and alcoholism severity are risk factors for poor outcomes in treating alcoholism, little is known about whether clinicians assess these conditions accurately. In this study we evaluated four clinicians' assessments of two indicators of alcoholism severity and three psychiatric co-morbidities in 78 inpatients in their third to seventh day of hospitalization in alcohol treatment programs. Clinicians overestimated the number of days drinking in 28% of subjects, and the number of drinks per drinking day in 37% of subjects. Clinicians underestimated alcohol consumption for patients with higher incomes. Clinicians correctly diagnosed 67% of 18 subjects with antisocial personality disorder, 65% of 26 with major depression, and 89% of 28 with drug abuse. These preliminary results need to be replicated in larger samples of clinicians to determine whether interventions are needed to improve the recognition of important prognostic factors in the treatment of alcoholic patients.     

Review of From denial to recovery: Counseling problem drinkers, alcoholics, and their families.

Reviews the book, From denial to recovery: Counseling problem drinkers, alcoholics, and their families by Lawrence Metzger (see record 1987-98723-000). This book admirably complies with the author's stated reason for writing it: "A compelling reason for writing this book is to aid care givers who may have avoided or been baffled by alcoholic clients in the past. Their lack of training and expertise in dealing with this problem has meant that alcoholics and their family members...have been neglected to the point where the problem simply becomes self-perpetuating and expands generationally." To this end, this book can serve as an excellent introduction to the field of alcoholism treatment for practitioners trained in the behavioral sciences. Unlike many works in the alcoholism literature, this book is properly annotated and, to a large degree, research based. As such, it will appeal to practitioners with a scientific background. The author proceeds to give an excellent overview of the current state of the art in alcoholism treatment. None of the particular criticisms noted should detract from these general observations. Overall, the major strength of this work is its explication of the details of alcoholism treatment in a format which will be palatable to students of the behavioral sciences. It would be an excellent addition to courses on addictions treatment. The most specific strengths of this work are in the diagnostic formulation for differentiating levels of alcohol abuse and the explication of a very thorough alcoholism diagnostic interview. In my view, if the reader can remember that (a) alcoholism is not caused by bad genes, (b) patients who have blackouts must abstain from alcohol, and (c) the self-help movements are the primary treatment modalities for addictions, then this work will be an excellent addition to any library on alcoholism. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Alcoholism treatment: Context, process, and outcome.

Reviews the book, Alcoholism treatment: Context, process, and outcome by Rudolf H. Moos, John W. Finney, and Ruth C. Cronkite (see record 1990-98391-000). The research of Moos, Finney, Cronkite, and colleagues, which is summarized in the present volume, has been pivotal in drawing attention to the role of extratreatment factors in the alcohol recovery process. Their work demonstrates the limited influence of patient- and treatment-specific characteristics in predicting long-term outcomes and shows that extratreatment, contextual factors such as life events, family and social resources, and coping responses, add significantly to the prediction of outcomes as long as 10 years after treatment. These findings raise important questions about the utility of treatment outcome studies that focus exclusively on treatment-produced behavior change and that ignore the broader life context in which treatment is administered. The book details the empirical bases of these conclusions and summarizes the authors' 10-year outcome evaluation of five inpatient and residential alcohol treatment programs. Although the work of Moos and colleagues has been instrumental in directing attention toward contextual variables, their measurement and data-analytic practices are probably inadequate to explicate thoroughly how life contexts influence the drinking patterns of individual problem drinkers over time, which are the kinds of data that will best inform the development of interventions to enhance natural contingencies that promote abstinence. Without exception, their follow-up measures were discontinuous and yielded only summary indices of subjects' drinking behavior and functional status on the life context variables. This and other limitations regarding measurement and conceptualization notwithstanding, the Moos et al study stands as a landmark investigation revealing the critical influence of life context factors on the lengthy process of recovery from alcoholism. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The disease controversy and psychotherapy with alcoholics

This article discusses conducting psychotherapy with alcoholics in light of the controversy about whether alcoholism is a disease. The belief that alcoholism is a disease forces many clinicians to offer abstinence from alcohol as the only option for alcoholics who seek treatment. From this perspective, the alcoholic must be helped to accept the idea that he or she has a disease and that to recover from this problem, drinking must stop. Others maintain that alcoholism may not be a disease and view alcoholic drinking as maladaptive behavior. From this vantage point, helping the patient to control or to moderate drinking might be considered. These two distinct paradigms lead to divergent treatment goals, which leaves the clinician in a quandary about how best to treat an individual who experiences a drinking problem. To resolve this dilemma, it is suggested that the clinician who works with alcoholics entertain a multiplicity of perspectives and should not be blinded by any one paradigm. While control of alcohol intake must take place if such patients are to improve their functioning, the author argues that recovery can occur either by abstinence or through moderating drinking.     

Bridging the gap between laboratory and clinic in child and adolescent psychotherapy.

Meta-analyses of laboratory outcome studies reveal beneficial effects of psychotherapy with children and adolescents. However, the research therapy in most of those lab studies differs from everyday clinic therapy in several ways, and the 9 studies of clinic therapy the authors have found show markedly poorer outcomes than research therapy studies. These findings suggest a need to bridge the long-standing gap between outcome researchers and clinicians. Three kinds of bridging research are proposed and illustrated: (a) enriching the research data base on treatment effects by practitioners in clinical settings—including private practice and health maintenance organizations, (b) identifying features of research therapy that account for positive outcomes and applying those features to clinical practice, and (c) exporting lab-tested treatments to clinics and assessing their effects with referred youths. If these bridging strategies were widely adopted, despite the numerous obstacles described herein, real progress might be made toward more effective treatment in clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Functional impairment and coping style.

The study of how patient attributes interact with psychological treatments (i.e., aptitude by treatment interactions [ATI's]) is a complex and often neglected area of research. ATI research includes patient dimensions and covariates or moderators that selectively and predictably alter the effect of various models of psychotherapy. A number of patient dimensions that moderate treatment effects have been identified. This article focuses on two of these patient variables: patient level of functional impairment and patient coping style. This article describes these concepts and the methods of their measurement and then reviews empirical literature that identifies the effects of these patient contributions on treatment outcome. The practical implications for treatment are also discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessing the comparative cost-effectiveness of alcoholism treatments: a comment on Holder, Longabaugh, Miller and Rubonis

Holder, Longabaugh, Miller and Rubonis (JSA, vol. 53, pp. 517-540, 1991) discuss the shortcomings of the empirical literature relevant to an assessment of the comparative cost-effectiveness of alcoholism treatment modalities. Their analysis is rooted in an attempt to conjoin the literatures pertaining to clinical efficacy and costs of alcohol dependence treatment. Holder et al.'s methodology is flawed in a number of respects and they exceed the bounds of the evidence when they endorse particular treatment modalities as comparatively cost-effective. Generalizations as to the relative cost-effectiveness of particular modalities are forwarded despite the fact that treatments are applied to persons with alcohol problems of widely varying severity. Additional points of contention are raised regarding the authors' selection of acceptable studies and interpretation of findings. Despite these limitations, Holder et al.'s (1991) analysis is a seminal heuristic contribution to the discussion of cost-effectiveness in the alcoholism field.     

Matching treatment to alcoholism subtypes.

In the field of alcoholism treatment, as in mental health treatment more generally, no one treatment model is equally effective for all patients and problem types. Literature in both alcohol treatment and in psychotherapy research suggests some relationships in common between treatment efficacy and patient coping style, drinking patterns, and family dynamics. This literature suggests that "internalizing" alcoholics, whose drinking tends to be steady and to be functionally interwoven with family dynamics, will benefit more from family systems oriented treatments than from symptom- or individually focused treatments. Conversely, "externalizing" alcoholics may derive more benefit from symptom-focused cognitive and behavioral treatments than from family systems treatment. An ongoing research project designed to test these hypotheses and the development of treatment manuals that may increase differential treatment efficacy is described. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Alcohol and the family: Research and clinical perspectives.

Reviews the book, Alcohol and the family: Research and clinical perspectives, edited by R. Lorraine Collins, Kenneth E. Leonard, and John Searles (see record 1990-97558-000). Alcohol and the family is divided into three parts. Part I describes the research on genetic influences that may determine whether someone develops a problem with alcohol. Part II focuses on family processes as they influence drinking behavior. Part III discusses various aspects of family-oriented treatment. Although this book does not purport to be a clinician's handbook, parts II and III provide a well-written, concise, and helpful discussion both of the role of family processes in the development and maintenance of drinking problems and of family approaches to their treatment. This book is "intended for both researchers and clinicians who have an interest in alcoholism and/or family related issues. [The editors] hope that the issues raised in the chapters in this volume will stimulate further developments in research and clinical endeavors on alcohol and the family." Indeed they will. This is a book worth reading by those with such interests, despite a few minor shortcomings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessment of alcohol use with multidimensional concepts and measures.

Reviews the results of selected studies by the authors (1969, 1970, and 1973) on 5,000 patients undergoing treatment for alcoholism. Findings support a multidimensional perspective of alcoholism. Data on the covariations among self-reported symptoms and other drinking-related variables indicate 15 psychometrically independent 1st-order factors and 5 broad 2nd-order dimensions. These factors provide reliable operational definitions of alcoholism that correspond to different constructs and have different relations to variables reflecting etiology, personality, treatment outcome, and life-span development. These factors provide a basis for the diagnosis of a variety of alcohol-related problems and for the design of effective programs of therapy. It is concluded that future research on alcohol abuse should be based on multivariate measurement. (71 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessing risk for completed suicide in patients with alcohol dependence: Clinicians' views of critical factors.

The assessment of potential for suicide among patients with a diagnosis of alcohol dependence has consistently been a dilemma for clinicians. Specifically, a problem for both clinicians and researchers has been determining what risk factors distinguish patients with suicidal ideation from those that are in danger of completed suicide. Identifying what clinicians who specialize in substance abuse view as critical in the assessment and treatment of suicidal patients is a first step in gaining a greater understanding of suicide risk within an alcoholic population. The views of these clinicians are presented and compared with empirical findings on the subject. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic Stress Disorder in Youth: A Critical Review of the Cognitive and Behavioral Treatment Outcome Literature.

What treatments work for children who have posttraumatic stress disorder (PTSD)? Perhaps more important, what else do clinicians need to learn? In this article, the authors focus on treatment research in the area of trauma and PTSD in youth, in an attempt to highlight the clinical implications of such work and to identify the areas in which additional research is needed. Overall, there is emerging evidence that a variety of cognitive and behavioral programs are effective in treating youth with PTSD. In spite of such evidence, additional research is needed to shore up the scientific base for effective clinical practice with these youth. Psychologists working with traumatized youth will find this article a useful update on the state of evidence for cognitive-behavioral interventions in the treatment of PTSD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Editorial introduction.

This editorial discusses the Special Section on New Psychotherapy Treatments. The articles in this section each present individual studies of new psychotherapeutic treatments or literature reviews of research on such treatments. These studies do not meet what currently is viewed as the methodological gold standard for treatment outcome studies in our field. Instead, they generally represent beginning efforts at studying new treatments. They reflect the kinds of studies and reviews that have great heuristic potential, and they also ought to be of value to the psychotherapy practitioner. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Introduction to the special section: research on the nature and treatment of alcoholism--does one inform the other?

Although the 2 topics of the nature and treatment of alcoholism have both been investigated for years, they are just recently beginning to interface with and complement one another. This special section addresses the interface from both perspectives and covers content areas that touch on current issues, research and treatment trends, and controversies in the alcohol field. The first 2 articles focus on the nature of alcoholism with commentary on implications for treatment, and the second 4 articles shift to examine research on treatment of alcohol problems, with implications for understanding the nature of alcoholism. This introductory article describes the special section, summarizes the articles in the section and integrates the information to discuss areas of increasing interface between research on the nature and treatment of heterogeneous substance abuse problems.     

Complex HIV treatment regimens and patient quality of life.

Recent advances in the treatment of HIV/AIDS have led to medical improvements for persons living with the virus. As a result, many now think of HIV infection as a chronic rather than a terminal illness. Along with this shift comes the understanding that individuals now live with treatments that require long-term adherence to regimens that are often complex, time consuming, and not without deleterious side effects. The greater life expectancy, nature of new treatments and their dependence on regimented adherence has recently led to the investigation of psychosocial variables loosely categorized as quality of life (QOL). Although there has been relatively little research on the topic in relation to new HIV therapies, what is known is that QOL--with all of its complications and dimensions--appears to play an essential role in HIV and HIV treatment. Moreover, QOL would seem to be a most worthwhile component to further investigations of improved therapies and betterment for the lives of infected individuals. The following literature review discusses these issues, highlights key research findings, and provides directions for further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The etiology and diagnosis of alcohol dependence: Differences in the professional literature.

Recent epidemiological studies indicate that alcohol-related problems continue to be widespread and include multiple medical, psychological, family, and social consequences. However, numerous debates exist among clinicians, recovery counselors, and researchers regarding a variety of issues related to alcohol dependence assessment and treatment. Controversies include different views about etiology, diagnosis, disease-versus-syndrome concepts, and the relationship between Alcoholics Anonymous and professional researchers and clinicians. This article informs and clarifies these controversies by highlighting recent findings from the empirical and theoretical literature. If the field of psychology is to effectively impact the alcohol treatment field, clinicians must implement specific diagnostic and intervention strategies that are based on the existing alcohol literature rather than theoretical bias. Recommendations include strategies for increasing collaboration among clinicians, researchers, and recovery counselors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacotherapies for alcohol abuse. Withdrawal and treatment

Pharmacologic management of alcoholism is only one part of the management of both alcohol dependence and withdrawal, which also includes the provision of a calm, quiet environment; reassurance; ongoing reassessment; attention to fluid and electrolyte disorders; treatment of coexisting addictions and common medical, surgical, and psychiatric comorbidities; and referral for ongoing psychosocial and medical treatment. For further discussion of these topics, the reader is referred to previously published sources. A survey of alcoholism treatment programs revealed that although benzodiazepines were the most commonly used drugs, standardized monitoring of patients' withdrawal severity was not common practice, and a significant minority of clinicians were using a variety of other drugs, some not known to prevent or treat the complications of withdrawal. Treatment should be based on the available evidence (Working Group on Pharmacological Management of Alcohol Withdrawal: American Society of Addiction Medicine Committee on Practice Guidelines: Pharmacological management of alcohol withdrawal: An evidence-based practice guideline. Unpublished draft, 1997). Patients with significant symptoms, patients with complications such as seizures or delirium tremens, and patients at higher risk for complications of alcohol withdrawal should receive benzodiazepines, particularly chlordiazepoxide, diazepam, or lorazepam, because of their safety and documented efficacy in preventing and treating the most serious complications of alcohol withdrawal. These drugs may be dosed on a fixed schedule for a predetermined number of doses on a tapering schedule over several days, or they may be administered by front-loading. An alternative approach for selected patients without seizures or acute comorbidity is symptom-triggered therapy, which individualizes treatment and decreases the duration and dose of medication administration. With either of the regimens, patients should have their withdrawal severity monitored until symptoms are resolving. Once withdrawal from alcohol is safely completed, the focus should turn to helping to prevent relapse. Disulfiram may be useful in highly motivated subsets of patients and when compliance-enhancing strategies are used. Naltrexone is useful in the broader population of patients entering treatment for alcohol dependence. These pharmacologic interventions should be given in the context of ongoing psychosocial support. There is substantial evidence that pharmacologic management of alcohol abuse and dependence is effective. As would be predicted from alcohol's myriad cellular effects, no panacea exists for alcoholism. For alcohol withdrawal, however, although treatment regimens have only recently been refined, evidence for effective treatment of symptoms and prevention of complications with benzodiazepines has been available for decades. Within the last decade, effective treatments, including naltrexone, have been shown to reduce alcohol intake in alcohol-dependent persons. Given the prevalence and cost of alcohol-related problems, all effective therapies (including pharmacologic treatments) should be considered to treat alcohol abuse and dependence.     

A strategy for applied research: Learning based but outcome oriented.

Argues that graduate training and the policies of journals and granting agencies promote a view of research that is effective for the scientific understanding of behavior but not productive of effective clinical treatments based on that understanding. By devising treatments based on learning principles, but emphasizing clinical outcome, and scientifically evaluating these treatments, a methodology to bridge this gap is proposed. This new strategy was applied to many different problem areas including training profoundly retarded persons, controlling aggression, toilet training, marital adjustment, stuttering, alcoholism, tics, and job finding. Success in developing effective treatments requires a research strategy that emphasizes clinically important dimensions. (44 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Outcomes of treatment for alcohol problems: Current methods, problems, and results.

This overview of current methods, problems, and results of psychological treatment for alcohol abuse, including alcoholism, begins by considering three common and troublesome assumptions about such treatment. A discussion of external and internal validity problems that are specific to alcoholism treatment research follows, and promising solutions are reviewed. Current data are discussed on who is treated for alcohol problems in this country. Next, detailed consideration is given to factors that predict response to alcoholism treatment, including variables associated with treatment type, setting, and intensity; such factors specific to patients as age, gender, ethnicity, socioeconomic status and education, psychopathology, marital and occupational status, and motivation for change; and environmental and other extratreatment factors. The article concludes with a review of current data on nonproblem-drinking treatment goals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)