National Addiction Centre, Maudsley Hospital/Institute of Psychiatry, 4 Windsor Walk, London SE5 8RF, UK
(Received 14 March 2003; first review notified 27 March 2003; in revised form 25 April 2003; accepted 5 May 2003)
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ABSTRACT |
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INTRODUCTION |
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Although AA has claimed a 75% sobriety rate for drinkers who seriously invest in the programme (Alcoholics Anonymous, 1976; Thurstin et al., 1987
), other sources estimated that 50% of AA participants drop out within the first 3 months (Chappel, 1993
). However, increased abstinence has been reported among those attending AA following substance misuse treatment (Emrick, 1987
; Christo and Franey, 1995
; Humphreys et al., 1998
; Ouimette et al., 1998
; Fiorentine, 1999
), and lower rates of relapse have been found to be associated with more frequent attendance at AA (Humphreys et al., 1997
; Caldwell and Cutter, 1998
; Fiorentine and Hillhouse, 2000
). Affiliation with AA has been found to be more predictive of positive outcomes than attendance alone (McLatchie and Lomp, 1988
; Miller and Verinis, 1995
; Montgomery et al., 1995
; Morgenstern et al., 1997
).
In Project MATCH, those randomized to Twelve-Step Facilitation attended more AA meetings, and AA involvement was associated with better 3-year outcomes, specially for drinkers with social networks which were supportive of drinking (Longabaugh et al., 1998). Ouimette et al. (1997)
also found that Twelve-Step and cognitive behavioural approaches were equally effective in maintaining abstinence from alcohol, and in reducing depression and anxiety.
Not all studies have found improved outcomes associated with AA attendance (McLatchie and Lomp, 1988; Miller et al., 1992
; McCrady et al., 1996
). The positive outcomes associated with AA attendance often declined after 6 or 12 months (Alford, 1980
; Wells et al., 1994
). Also, most AA research studies have been conducted in the US. Because of cultural differences in healthcare provision and treatment goals, this may not generalize to a UK context. While there are currently about 3500 AA meetings in the UK each week (Personal Communication with the AA General Service Board, 2003), little is known about AAs role within UK substance misuse treatment services.
The present study is a longitudinal investigation of patients receiving treatment for alcohol problems within a specialist National Health Service (NHS) inpatient alcoholism treatment service. It reports patient outcomes for alcohol consumption, alcohol-related problems, psychological problems and subjective quality of life measures during the 6 months following treatment completion. In particular, it investigates the relationship between attendance at AA meetings prior to, during and after leaving treatment, and changes in clinical outcome.
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SUBJECTS AND METHODS |
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Procedure and measures
There were no selection criteria other than alcohol dependence: all consecutive admissions to the inpatient unit were approached by an independent researcher (i.e. not part of the treatment team) and invited to participate. No data are available on refusal rates though this was low (less than 10%). A longitudinal design was used in which consenting participants were interviewed at admission (within 5 days of entry), and 6 months following discharge.
At each interview, participants completed a 60-minute, semi-structured interview, assessing drinking history, drinking behaviour, health and wider lifestyle issues. Assessment was made of frequency and quantity of alcohol use during the 30 days prior to each interview. Frequency of drinking was also assessed for the period since departure from the inpatient programme. A variable was created for percentage drinking days; this was calculated as the number of self-reported days drinking for the period between leaving the index treatment and the follow-up interview divided by the total number of days in the community (i.e. in a non-protected environment). The Alcohol Problems Questionnaire (Drummond, 1990) was used to assess alcohol problems during the 6 month periods prior to admission to treatment and prior to follow-up. Alcohol dependence was assessed using the Severity of Alcohol Dependence Questionnaire (Stockwell et al., 1979
). The Symptoms Checklist-53 (Derogatis, 1993
) was used to obtain measures of psychiatric problems (Global Severity Index, Symptom Total, Symptom Distress scores), and of caseness for nine primary symptom dimensions. Chubons (1995)
Life Situation Survey was used as a measure of quality of life.
Participants
Patients (n = 150) were interviewed an average of 2.1 (SD = 1.7) days following entry to the inpatient unit. All met ICD-10 criteria (World Health Organization, 1992) for alcohol dependence (F10.2). The sample subjects were contacted for follow-up by home visit, telephone and/or letter inviting them to complete a follow-up interview. Of the recruited sample, 120 (80%) were successfully contacted for the follow-up interview. Follow-up interviews took place, on average 159 days (5.3 months) following the patients discharge from treatment. Follow-up data were missing for 30 (20%) participants. This was for a number of reasons; two patients had died, five refused to participate further in the study, and 23 were uncontactable.
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RESULTS |
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To further examine the comparability of the two groups, the following variables were entered into a logistic regression to predict follow-up status: age at entry to treatment, pre-entry drinking (frequency and amount), severity of dependence, number of alcohol problems, psychiatric problems, quality of life, drinking and treatment history and previous AA attendance. While the model was significant at the 5% level (2 = 29.7; d.f. = 14; P < 0.05), none of the individual variables was statistically significant. The results suggest that those who were followed up were broadly similar to those who were not followed up in terms of pre-admission characteristics and problems.
Demographic profile and drinking problems at intake.
The sample consisted of 38 (25.3%) women and 112 (74.7%) men. Thirty-six (25%) were married or cohabiting, 57 (39%) were single and 53 (36%) divorced, separated or widowed. The majority were receiving social security/unemployment benefits (116; 80%) in the month prior to admission; 23 (16%) had been working, and six (4%) were retired (n = 145, valid demographic data). The majority (79; 54%) were living in rented accommodation, 35 (24%) in owned accommodation, 27 (19%) with friends or family, and one was receiving treatment in hospital.
The sample had been drinking for an average ± SD of 22.4 ± 10.2 years (range 251 years) and drinking problematically for an average of 11.5 ± 8.5 years (range 140 years). They reported first seeking alcohol treatment at a mean age of 37.4 years, an average of 4.8 years before entry into the current inpatient treatment and an average of 6.8 ± 7.2 years (range 040 years) after initiating problematic drinking.
At intake, the sample reported high levels of alcohol dependence (61% had SADQ scores of more than 30, denoting severe alcohol dependence), a large number of alcohol-related problems, high levels of psychiatric problems and poor quality of life.
Changes in alcohol consumption (for month prior to interview)
The proportion of participants who had consumed alcohol in the previous month fell from intake to 6-month follow-up: 148 (99%) were drinking in the month prior to treatment entry compared with 84 (70%) of those re-interviewed at 6 months. Half of the sample (61; 51%) reported drinking on a less frequent basis at follow-up, and more than two-thirds (82; 70%) reported a reduction in drinking amounts per day. These changes are also reflected in the reductions in mean frequency of drinking and in mean amounts of alcohol per day consumed at follow-up (see Table 1). There was also a reduction in the proportion who reported daily drinking, from 128 (86%) in the month prior to admission to 58 (48%) at follow-up (McNemar test, P < 0.001).
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Time to first lapse and percentage drinking days (during 6-month follow-up period)
More than three-quarters of the sample (95; 79%) reported consuming alcohol at some point during the 6 months following their inpatient treatment. Average time to first lapse was 44.5 ± 57.7 days. For about half of those reporting a lapse to alcohol (48%), this occurred within 3 weeks of their departure from the inpatient treatment unit.
Due to individual variations in the time between leaving treatment and the follow-up interviews, the variable percentage drinking days was calculated to represent the relationship between actual drinking and days available for drinking during the period between treatment departure and follow-up. During this time, 25 (21%) had not consumed alcohol: 31 (26%) had consumed alcohol on up to a quarter of available drinking days: 25 (21%) on between a quarter and three-quarters of available drinking days; and 38 (32%) on more than three-quarters of all available days, of whom 11 reported drinking on a daily basis during the entire follow-up period.
Attendance at AA
Nearly three-quarters of the intake sample had attended at least one AA meeting prior to their current inpatient episode, and just over half had attended in the previous year (see Table 2). Forty percent (n = 48) attended AA during the follow-up period, of whom seven (15%) had never attended AA prior to the index treatment episode. Of those attending AA during the follow-up period, 35% (17/48) attended on a weekly (or more frequent) basis, and 65% (31/48) on a less than weekly basis. Only one participant reported attending AAs recommended 90 meetings in 90 days.
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AA attendance and outcomes
Those attending AA during the follow-up period reported drinking on a less frequent basis than did non-AA attenders, both in the month prior to follow-up (AA attenders: 14.2 ± 14.0 days; non-attenders: 19.2 ± 13.1 days; t = 2.0; d.f. = 118; P < 0.05), and during the entire follow-up period (AA attenders: mean = 31 ± 34.8% drinking days; non-attenders: mean = 53 ± 40.7% drinking days; t = 3.9; d.f. = 110.6; P < 0.01). Among the follow-up sample, there were no significant differences between AA-attenders and non-attenders at follow-up in terms of drinking frequency (t = 1.9; d.f. = 118; P = 0.06) or changes in daily drinking amounts (t = 1.9; d.f. = 115; P = 0.06), although differences approached the 5% level of statistical significance for each of these variables.
In order to conduct more detailed analyses of these results with regard to frequency of AA attendance, three attendance groups were constructed: those who did not attend AA after treatment, infrequent attenders (less than weekly post-treatment attendance at AA), and frequent attenders (more than weekly). There were no significant differences between the three AA attendance groups in terms of the following pre-intake characteristics: amounts of alcohol consumed per day, severity of alcohol dependence, alcohol problems, psychiatric problems and number of other treatments received during the follow-up period (see Table 3). There was a difference with regard to drinking frequency at intake. While not significantly differing from those not attending AA during the follow-up period, those who attended AA on a weekly or more frequent basis reported less frequent drinking at treatment entry than those attending AA on a less than weekly basis.
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Those variables that were found to differentiate between the three AA follow-up groups (baseline drinking frequency and days in treatment at the inpatient unit), and the number of additional treatment services contacted during the follow-up period (which was of borderline statistical significance) were entered as covariates in subsequent univariate analyses of covariance (ANCOVA). This did not alter the significant relationship between frequency of AA attendance and outcome drinking frequency. After controlling for baseline percentage drinking days, days in treatment and further treatment contacts, frequency of AA attendance was negatively associated with percentage drinking days during the follow-up period (F = 5.2; P < 0.01). A similar negative relationship was found between frequency of AA attendance and number of drinking days in the month prior to the follow-up interview (F = 4.3; P < 0.05).
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DISCUSSION |
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The benefits associated with AA attendance were limited to a relatively small proportion of patients. Less than half of the sample reported post-treatment AA attendance, and only 15% reported attending AA meetings on a weekly or more frequent basis after treatment. However, the relationship between improved drinking outcomes and frequent AA attendance mirrors that found by Fiorentine (1999). The consistency of these findings is interesting in view of the differences in sample characteristics, follow-up times and measurement methods in these two studies. In comparison to Fiorentine (1999)
, the present study reported relatively low levels of AA attendance and affiliation.
Although improvements in alcohol consumption, alcohol-related problems and in lifestyle domains were reported by the sample as a whole, the association between enhanced outcomes and frequent AA attendance related only to drinking outcomes. Frequent AA attendance was not associated with reduced psychiatric problems nor with improved subjectively reported quality of life. It is possible that changes in drinking may occur prior to changes in other areas of functioning, or that a 6-month follow-up period covers too short a time period to observe a relationship between AA attendance and the lifestyle domains. It is also possible that psychological health and quality of life problems which were previously masked by heavy alcohol use become more salient during periods of sobriety. Whatever the interpretation of this finding, and despite the improvements in drinking observed at follow-up, the psychological health of many of the sample was still poor with average symptom scores remaining higher than norms for adult psychiatric inpatients (Derogatis, 1993).
As inpatient alcohol treatment services tend to see more complex and more severely problematic cases (Weiss, 1999), it is unrealistic to expect short-term treatment interventions to produce and maintain improvements in the absence of additional supportive care, and the support provided by AA may not be appropriate or sufficient to produce change in such problems. Despite the overall improvements, the continued psychiatric problems, generally poor quality of life and relatively high rates of problematic drinking at follow-up indicate the need for more comprehensive treatment input and aftercare.
This is the first study of an NHS programme to present such data. The study has a number of limitations. Patients were not randomly allocated to AA and non-AA conditions. The naturalistic design may have allowed some confounding of results due to a selection bias in the characteristics of those who attended AA, though post hoc control of intake variables suggested few differences between AA attenders and non-attenders. Also, as in other longitudinal studies, a certain number of participants were lost to follow-up, though the follow-up rate of 80% represents a satisfactory achievement. Although the patients who were recruited to the study but not interviewed at follow-up reported attending fewer AA meetings prior to treatment, when statistical controls were made for pre-treatment drinking behaviour and other problems, no relationship was found between pre-treatment AA attendance and outcomes at follow-up. Nor was there any relationship between pre-treatment and post-treatment attendance at AA meetings.
Future research might consider the use of longer follow-up periods, and more detailed investigation of motivation and behaviour during the period following treatment. Greater consideration of process issues is also required, with more detailed investigation of AA involvement, the temporal relationship between meeting attendance, lapses and other treatment attendance, and an exploration of the mechanisms through which AA attendance supports or enhances drinking outcomes (Moos et al., 1990; Montgomery et al., 1993
; Timko et al., 1994
, 1995
; Tonigan et al., 1995
, 1996
; Finney and Moos, 1996
).
The importance of aftercare has long been acknowledged. Despite this, most treatment systems continue to suffer from a marked lack of adequate aftercare services. The findings suggest that AA can provide a useful aftercare resource and that regular contact with AA may help to maintain the benefits initially accrued from alcohol treatment programmes. Regular AA attendance, particularly in a group where members feel supported, comfortable and among like-minded people, may provide a means of sustaining the gains obtained during inpatient alcohol treatment. Closer liaison between NHS treatment units and local AA groups could be encouraged, with sponsor visits to the treatment service and members from local AA groups contacting patients at the time of leaving treatment. However, some features of Twelve-Step treatment tend to be more acceptable than others to alcoholics (Best et al., 2001), and AA affiliation will not appeal to, or be a feasible option for all patients.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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