University of Glasgow, Department of Psychological Medicine and
1 Alcohol Problems Treatment Unit, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 0XH and
2 Community Alcohol Service, Goldenhill Resource Centre, 2 Stewart Drive, Clydebank, Glasgow G81 6AH, UK
Received 8 December 2000; in revised form 6 September 2001; accepted 10 October 2001
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ABSTRACT |
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INTRODUCTION |
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SUBJECTS AND METHODS |
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The home detoxification sample consisted of 29 patients, 20 men (69%) and nine (31%) women. The mean ± SD age was 46.4 ± 12.2 years, 35% were married and 62% were unemployed. Two-thirds of the group scored >30 on the Severity of Alcohol Dependence Questionnaire (SADQ) which is the cut-off point indicating severe dependence (Stockwell et al., 1983). Patients reported drinking a mean of 178 units of alcohol (the equivalent of 5.5 bottles of spirits) in the week before detoxification. (A UK unit is equivalent to a glass of wine, or a public bar measure of spirits, or to 0.5 pint of beer, each unit containing
1 cl/7.9 g of absolute alcohol.) Thirteen (45%) had required assistance to detoxify previously, and of these, six (21%) had episodes of in-patient detoxification.
The day hospital group (n = 36) had the same proportion of men and women. The mean ± SD age was 45.1 ± 9.8 years, 37% were married and 82% were unemployed. There were no statistically significant differences between the two groups on sociodemographic indices. In terms of units, this group reported consuming 194 units in the week before detoxification. A higher proportion of day hospital patients were in the severe dependence category (81%), although there was no statistically significant difference in overall SADQ scores. Twenty-six patients (72%) had previously required help to detoxify, 14 (39%) of whom had been detoxified as in-patients. On the Alcohol Problems Questionnaire (APQ) (Drummond, 1990) both groups reported major difficulties, although the hospital group reported more problems. This reached statistical significance in the case of general problems, also on a separate measure of social disruption (Smart, 1979
), but not for other indicators. Despite the severity of problems described, both types of detoxification proved effective for withdrawing patients from alcohol and, at 10 days, 79% of the home group and 78% of the hospital group were successfully detoxified.
At 60 days, the following outcome categories were used. Good indicated complete abstinence from alcohol, or drinking <8 units per week and no return to alcohol-related problems reported by direct interview with the patient and confirmed by breathalyser and an independent source (a relative or, if none available, referral agent or treatment staff). Improved indicated that, if drinking had occurred, this did not exceed 21 units per week, dependence was not reinstated and the APQ was zero. The final category was unimproved, which contained patients drinking in excess of 21 units per week or who were once more physically dependent and reporting alcohol-related problems.
As would be expected in groups with such severe problems, attrition rates were high and, by 60 days, 65% of home detoxification patients and 56% of the day hospital group were successfully re-interviewed in person. In terms of outcome, 45% of the home group and 31% of the hospital group were in the good outcome category and a further 17% and 3% were in the improved category respectively. A further 28% of the home group and 44% of the day group were in the unimproved category and 10% (n = 3) and 19% (n = 7) respectively were completely lost to follow-up. One patient in the hospital group died from causes unrelated to detoxification. When considering longer-term outcome, the general indications are that, given the initial levels of severity, outcome is similar to that reported for comparable UK studies (Stockwell et al., 1990; Bennie, 1998
).
Patients who had attended for treatment after the conclusion of detoxification had significantly superior outcomes. For the home group, the most frequently used treatment was further individual sessions with the CPN, followed by attendance at a City Centre Alcohol Day Service. For the hospital group, attendance at a structured Alcohol Day Programme, which operates within the same premises as the detoxification service, was the most likely treatment option to be taken.
Methods
Patients were interviewed at the beginning of detoxification and follow-up interviews were conducted at 10 days and 60 days by a research assistant not involved in the delivery of treatment. The schedule consisted of a structured interview and self-report questionnaires (see Allan et al., 2000 for full details) which included a measure of psychological symptoms which were assessed by using the shortened version of the General Health Questionnaire (GHQ), which consisted of 28 items (Goldberg and Hillier, 1979
). A threshold score of
5 was used by Goldberg and Hillier (1979) to indicate a case. There are a number of major difficulties in accurate diagnostic assessment when individuals are drinking heavily for long periods of time and experiencing regular withdrawal symptoms (Raimo and Schuckit, 1998
). Because of this the aim was rather to record the level of psychological symptoms and to observe the effect of periods of abstinence or periods of heavy drinking on their severity and frequency rather than to establish a diagnosis.
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RESULTS |
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Seventy-nine per cent of home patients and 78% of the hospital group were successfully detoxified at 10 days and examination of GHQ scores indicated that a further reduction to 11.7 ± 9.9 and 11.0 ± 8.5 respectively occurred during this period.
To examine if type of detoxification or gender were important, a two-way mixed ANOVA design was employed where sex and type of detoxification setting were between-subjects factors, and GHQ scores at beginning of detoxification and at 10 days were a within-subjects factor. Subjects (n = 51) still in treatment at 10 days and for whom there were complete data were included in the analysis. Results indicated that the main effects of sex [F(1,47) = 0.86, P < 0.36], type of detoxification [F(1,47) = 0.57, P < 0.45] or an interaction between the two [F(1,47) = 3.7, P < 0.06] were not statistically significant. Examination of the within-subjects factor indicated that there was a statistically significant change between GHQ scores at the beginning of detoxification and at 10 days [F(1,47) = 30.96, P < 0.0005], indicating a significant improvement in psychological symptoms during detoxification. In specific terms, 68% of home detoxification patients and 69% of day detoxification patients still met the criteria for caseness.
Outcome and psychological symptoms
Achieving longer-term abstinence was much more difficult and, by 60 days, only 45% of the home group and 31% of the day hospital group had maintained this state. As there appeared to be no major differences between the two samples in terms of psychological symptoms, the data were pooled to examine the relative effects of abstinence and resumption of problematic drinking. Patients (irrespective of detoxification setting) were divided into two groups, based on the previously described outcome criteria improved and not improved. The improved group was formed by amalgamating the good and improved groups, providing a dichotomous outcome category of improved and not improved. GHQ scores at two points were examined: 10 days after the start of detoxification and again at 60 days (Fig. 1). Subjects (n = 39) for whom there were complete data at 60 days were used in the analysis. A one-way mixed ANOVA was used with the outcome categories as the between-subject factor and GHQ score at two time points (day 10 and day 60) as the within-subjects factor. Results indicated that there was a significant effect between outcome categories [F(1,37) = 8.7, P < 0.006], and there was a significant effect for the within-subjects factor reduction in GHQ scores [F(1,37) = 4.9, P < 0.03]. There was also a significant interaction between outcome and GHQ scores [F(1,37) = 7.9, P < 0.008]. This is presented graphically, indicating that in the improved group (where patients had remained abstinent or virtually abstinent) there was a significant decline in psychological symptoms to almost asymptomatic levels. For those who resumed drinking after the 10-day detoxification period, no further improvement in GHQ scores occurred. In all, 77% of this group met criteria for caseness, as compared to the improved group where only 21% were in this category.
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DISCUSSION |
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The women included in this study reported rates of psychological symptoms similar to those of the men, and similar improvements occurred in both groups. It is possible to speculate that much of the previous work carried out on women was anecdotal or based on patients attending psychiatric in-patient facilities involving women who may be unrepresentative of female problem drinkers (Allan, 1991).
A further difficulty in this area has been the lack of an explicit theoretical position from which robust predictions can be made (Allan, 1995). Translating this into clinical terms, if alcohol misuse is secondary to a psychological condition, removal of alcohol through detoxification should either increase the psychological symptoms, as the coping response is no longer available, or should have little effect as the coping response (i.e. drinking) is largely ineffective. Conversely, if psychological symptoms are secondary to an alcohol problem, detoxification and a sustained period of abstinence should result in a significant decrease in the symptoms. Results from this study would indicate that the latter was a frequent occurrence for many patients, although some improvement may be due to use of psychotropic medication in association with abstinence.
Findings such as these can be translated into clinically relevant guidelines for the assessment and management of alcohol-dependent patients with complex presentations. This includes the recognition that most alcohol-dependent patients present with psychological symptoms, but, with even a brief period of abstinence supported by detoxification procedures, these will decrease rapidly. Previous research indicates that a minority of patients, perhaps as low as 10%, may then be left with more persistent symptoms which appear to constitute an independent clinical disorder (Brown et al., 1991), although in our study the rate of caseness in the improved group at 60 days was 21%. These patients can be treated using pharmacological or cognitivebehavioural approaches. The benefits of using antidepressant or anxiolytic medication must be balanced against the increased risk of side-effects or adverse reactions in people who continue to misuse alcohol or who have sustained physical complications (Scott et al., 1998
). We are unable to specifiy which other treatments the patients in the improved group had received.
The shape of services for those with co-morbid difficulties continues to be the subject of debate (Johnson, 1997) and has led to the call for the establishment of a psychiatric super-specialty to deal with patients who have these complex presentations. Other workers have suggested that a more realistic solution would be to support and inform staff in specialist mental health and addiction services about the assessment and management of the commonest and most remediable co-morbid disorders (Hall and Farrell, 1997
).
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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REFERENCES |
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